Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients being evaluated for brain death, which abnormal movements are definitively known to still be consistent with brain death and which are possibly consistent with brain death but lack definitive evidence?
This is indeed a challenging question, one that I continue to grapple with as a neurointensivist. Fortunately, most brain-dead patients do not exhibit any movements in response to noxious stimuli, but some case series report reflexive movement in up to 75% of cases. The classic teaching is that only...
Do you recommend immediate catheter removal or anticoagulating for a certain amount of time before removing the tunneled dialysis catheter of a patient with an incidentally found, asymptomatic thrombus at the end of the catheter that does not interfere with hemodialysis?
I agree with Dr. @Dr. First Last. Since this tunneled dialysis catheter (TDC) is functioning well, there is no urgency to remove it. Infact, removal runs the risk of dislodging the thrombus causing pulmonary embolism. I would provide systemic anticoagulation with a vitamin K antagonist (coumadin) us...
Do you routinely check cefepime levels in patient's with suspected cefepime-induced neurotoxicity?
No. I would never get the result soon enough. I just change the antibiotic.
For patients who have undergone ablation for atrial fibrillation with elevated bleeding risk, what is your risk/benefit approach when deciding to continue oral anticoagulation long-term?
I would generally determine the continuation of anticoagulation based on the patient's ChADSVASC score rather than the perceived success of ablation as many will have a burden of subclinical PAF despite ablation. So, if they are at high risk for stroke/systemic embolism, based on ChADSVASC, I would ...
How do you medically manage acute basilar artery occlusion in patients with low NIHSS who are not candidates for EVT but at risk for deterioration?
First, I would consider endovascular therapy even with a low NIHSS, if the patient is otherwise a good candidate. If this were not possible, I would angicoagulate with IV heparin initially, then a DOAC (direct oral anticoagulant).
At what ferritin threshold would a patient with anemia of inflammation or malignancy no longer benefit from iron supplementation for functional iron deficiency?
There is no level. I have given IV iron to people with low TSATs and ferritins in the thousands. 200 isn't even close to too high.
Do you avoid ESA use in patients with anemia and chronic kidney disease who also have APLS and risk for thrombosis?
I normally don't. I would make sure the patient is getting anticoagulated if indicated. I don't believe making the hemoglobin closer to normal in the setting of being anticoagulated increases thrombosis risk that much. I would shoot for a hemoglobin goal of 10-11.
Does hepatitis B vaccination reduce the risk of HBV reactivation associated with immunosuppressive therapy?
Hepatitis B reactivation is a critical concern when patients are undergoing immunosuppressive therapy, often described as 'deadly but preventable.' Screening for HBV is strongly advised before initiating biologic therapies, targeted synthetic therapies, or high-dose immunosuppression, including HBsA...
What is your approach to managing patients with labile blood pressures secondary to baroreflex failure?
Managing BP in the setting of baroreflex failure or dysautonomia is challenging. It is sometimes helpful to educate patients on realistic expectations. Medications will not be able to replace the baroreflex function. Conservative measures like compression socks during the day, bathroom modifications...
What immunosuppressive agents would be available to patients with a history of melanoma?
Generally, we try to use conventional synthetic DMARDs when possible. However, studies in RA have not shown an increase in de novo melanoma or recurrence of cancers more generally with TNF-inhibitors. So this is an option for patients with RA and melanoma history who are not responding to csDMARDs. ...