Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you consider DHE for patients with status migrainous with elevated blood pressure at the time of presentation?
No, I would not. DHE is a very potent and non-selective arterial vasoconstrictor and would potentially further increase elevated blood pressure. When a patient who presents with a headache is found to have elevated blood pressure, it should be assumed that the elevated blood pressure is the cause of...
Would you expect cinacalcet to lower calcium levels in a patient with Familial Hypocalciuric Hypercalcemia (FHH)?
The hypercalcemia in FHH is not primarily driven by overactive PTH secretion, so targeting the CaSR pharmacologically would not address the underlying pathophysiology. However, I suppose inducing hypoparathyroidism with Cinacalcet would induce calciuria, though at the expense of hypocalcemia.
Would you recommend desmopressin for a patient with ESKD receiving thrice weekly hemodialysis who is hospitalized for a persistent gastrointestinal bleed not amenable to usual interventional treatment strategies?
Yes. I always give desmopressin in patients with uncontrolled bleeding and uremia to fix the bleeding time abnormality. In this situation, the benefits should out way the possible harms.
What are reasonable alternatives to invasive angiography for CAV surveillance in patients who are a few years out from cardiac transplant with impaired renal function?
In our practice, we move to PET-CT on Year 3 if the prior 2 angiograms with IVUS did not show accelerating disease. The issue with CAV is that there is not much to do about it reactively. The best you can do, is switch to an mTORi regimen early and optimize lipids. IVUS is useful for that reason. Be...
Would you consider stepping down from an echinocandin to azole therapy prior to the end of an initial six-week course for fluconazole-susceptible Candida albicans endocarditis in the absence of valve surgery?
I would not step down to fluconazole prior to completing a six-week course of echinocandin therapy. Fluconazole has poor activity against Candida biofilms in contrast to the echinocandins. Fluconazole monotherapy has also been associated with poor outcomes in endocarditis. Admittedly, most of our un...
Is there a role for chronic suppressive oral or inhaled therapy for recurrent Burkholderia cepacia pneumonia causing frequent hospitalizations in a patient with severe bronchiectasis with or without underlying cystic fibrosis?
In certain cases, certainly, suppression may be the optimal role but in conjunction with modification to the immunosuppression. Generally, the immunosuppression will need to be lowered to allow for cellular immunity to combat the infection. Other factors include whether the gemovar is a more aggress...
How do you decide the right time for MitraClip intervention in patients with symptomatic heart failure and severe mitral regurgitation who are on maximally tolerated GDMT?
When evaluating these patients, it is always important to consider a multidisciplinary approach inclusive of general cardiologists, imaging experts for MR quantification, and most importantly, heart failure and electrophysiology colleagues. I ensure that the patient is seen by our HF colleagues to t...
Which class(es) of antihypertensives do you recommend for first-line therapy for hypertension in severe aortic stenosis?
Most beneficial data on ACE inhibitors.B blockers are to be avoided if associated AR but prior apparent contradiction is no longer valid and some benefit in outcomes based on their effects. Exact Aortic Stenosis substrate and comorbidities to determine which drugs to benefit. ARB's role is probably ...
What treatment would you offer a patient with extensive lymphangioma circumscriptum intermittently covering the entire abdomen?
I would consider sirolimus (rapamycin) to shrink the lesion to a size that could be surgically excised.
What is your approach to DVT prophylaxis in patients who require IVIG but are at increased risk for thrombotic events?
I am unaware of any published data to guide the decision-making for this topic. Empirically, I recommend low-dose aspirin in patients >50 who have to get long-term IVIG especially if there are a lot of underlying risk factors for thrombosis like diabetes, immobility, etc. Again, this is not an evide...