Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you typically recommend four factor prothrombin complex concentrate versus fresh frozen plasma for INR correction in patients with vitamin K antagonist associated spontaneous ICH?
Great question! Despite the lack of large randomized controlled trials, PCCs achieve faster reversal of the INR level than FFPs do, and thus I favor using PCCs with Vitamin K as a first line agent for Vitamin K antagonist related ICH.
Do you typically recommend CT angiogram and CT venogram to assess for patients with lobar spontaneous ICH?
For lobar hemorrhages I routinely obtain CTA (head/neck) & MRI (brain with contrast). On MRI, GRE/SWI sequences are good to look for micro-hemorrhage/amyloid-type of pathology. I only get MRA if patient has an elevated creatinine/CKD or anaphylaxis reaction to iodinated contrast. In my opinion, CTA ...
For a patient with high suspicion for NMDA receptor encephalitis, is there a role for giving rituximab along with methylprednisolone & IVIG (all three together) while the CSF anti-NMDAR antibodies are still pending?
The answer to this question was reported in Graus et al., PMID 26906964.
Do you routinely obtain an EEG in patients who are admitted with traumatic intra-cerebral hemorrhage?
We routinely obtain cEEG monitoring on all moderate (GCS 9-12) and severe (GCS 3-8) TBIs at our institution, regardless of their intracranial pathology. It is estimated that in this patient population, the frequency of sub-clinical seizures is around 20-25% and can be associated with elevated ICP, w...
How do you manage acute exacerbations of trigeminal neuralgia?
I do not have personal experience treating TN exacerbations in the ED. What is generally recommended under those circumstances is intravenous phenytoin. Schnell et al. recently published it in The Journal of Headache and Face Pain (Schnell et al., PMID 32981076). They published the results of a retr...
Would you recommend short-term dual antiplatelet therapy for a patient who received tPA, and is otherwise eligible for dual antiplatelet therapy per POINT or SAMMPRIS trial?
I would recommend dual antiplatelet therapy for 21 days for eligible patients. The risk of recurrence is highest in the first few days and patients will likely still benefit. I would just ensure the patient has no hemorrhage in their 24-hour scan and they would otherwise meet the criteria for the CH...
What is your practice for the timing of resumption of oral anticoagulation after ICH?
These are great questions and no good answers (therefore the question). In the near future, well-designed prospective studies and clinical trials will settle the uncertainties.Timing of resumption of anticoagulation has been addressed in modeling studies of risks of recurrent bleeding and thromboemb...
How do you approach the treatment of SREAT (steroid-responsive encephalopathy with autoimmune thyroiditis) after initial pulse dose steroids?
The diagnosis of this disease entity is hugely debated. I myself do not think that the diagnosis exists. A large segment of the normal population has antibodies and the goal of Rx in supposed cases is unclear/poorly defined.
Do you use a combination of anticoagulant and antiplatelet therapy for treating intraluminal internal cerebral artery thrombus causing stroke?
Yes, typically a combination of Intravenous heparin along with an anti-platelet agent (Aspirin or Plavix) is preferable. The natural history of intraluminal thrombus is variable, but the prognosis is usually favorable, and typically short-term follow-up vessel imaging can guide further anti-thrombot...
When do you redose IVIG in GBS patients who were under-treated and are worsening?
Based on recently published data from the randomized SID-GBS trial, this approach is not a good idea. A second course of IVIG not only did not clearly benefit patients with GBS with poor prognosis, but it was associated with a significantly higher risk of adverse events including thromboembolism. Wa...