Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there any role for palliative radiation in patients who are intubated due to malignant airway obstruction?
The literature is limited, but this small series showed about 1/4 of patients can have reversal of intubation.If the patient/family is interested in attempting, it occasionally works, but my own experience is less successful than 1/4. It is unlikely to worsen the situation, so after explaining that ...
Do you utilize urinary leukotrienes as a marker for initiation of montelukast?
No, I don’t. It is not readily available clinically and has not been shown to be predictive of response.
In your practice, when do you opt to treat unilateral primary hyperaldosteronism medically rather than surgically?
There should be a good reason for not pursuing surgery in a patient with unilateral primary aldosteronism. The surgery is more cost-effective. Some but not all data suggest a faster decrease in cardiovascular morbidity, a lower risk of atrial fibrillation, arterial stiffness, left ventricular mass, ...
Do you recommend routine use of Evusheld for pre-exposure prophylaxis for patients on immunosuppression?
The use of monoclonal antibodies as passive immunity for pre-exposure prophylaxis is an exciting development for vulnerable patients, including immunosuppressed patients (either primary or through medications such as for autoimmune diseases), cancer patients, and organ transplant recipients. Evushel...
Do you recommend daily topical exit site antibiotic use for patients with a peritoneal dialysis catheter that is only currently being accessed for once weekly flushes?
No. When PD catheters are being accessed only once weekly for flushes, we keep the exit site under a sterile dressing with a chlorhexidine-gluconate-impregnated disc surrounding the exit site. The catheter is accessed only by the PD nurse at the time of flushing, and we do not have the patient perfo...
How do you decide on the treatment target of burst suppression pattern vs seizure cessation for patients with status epilepticus?
There is no high-level data to support burst suppression as superior to electrographic seizure cessation, with data largely coming from case series. In general, those who reach burst suppression seem to have better seizure control, but at the expense of more side effects from the meds. Accordingly, ...
When is a biopsy necessary to diagnose relapsing polychondritis?
Since there are no specific lab tests for Relapsing Polychondritis, the diagnosis is based on clinical manifestations. Criteria proposed by McAdam et al. PMID 775252 require three or more of the following clinical features to confirm the diagnosis: Bilateral auricular chondritis Non-erosive, seroneg...
Do you use FVIII levels to differentiate between DIC and coagulopathy of liver disease?
DIC is a clinical diagnosis that is difficult to establish in the absence of bleeding or thrombosis, particularly in patients with liver disease. I do think that following DIC laboratory markers (FDP, fibrinogen, D-dimer) serially may be helpful as you would not expect them to acutely drop simply be...
Do you consider immunosuppressive agents in progressive interstitial pneumonias or pneumonitis without a clear driving etiology?
Although it's often helpful to have a clear diagnosis of an underlying connective tissue disease (CTD) or positive autoantibodies to guide therapy (or perhaps feel better about prescribing it), we more often find ourselves dealing with ambiguous cases. When pathology is available to suggest an infla...
How do you counsel patients with elevated factor VIII levels for their thrombosis risk?
I don't check the factor VIII level as part of a thrombosis workup because the result rarely if ever affects my management of these patients. I would explain to the patient that factor VIII levels are a function of several variables, including age, vascular health (and hence blood pressure, smoking,...