Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How often do you check carnitine levels in your patients with end stage kidney disease on hemodialysis?
About 10 years ago I used to check carnitine levels in ESRD patients with intradialytic hypotension commonly. If low then I would treat with levocarnitine. At some point I gave up on the practice not because it was not working but because it was hard to determine if it was working or not. I am aware...
What form of surveillance do you recommend for esophageal adenocarcinoma s/p NACRT and resection at what frequency?
We pretty much follow the NCCN guidelines. H&P every 3 months x 2 years, every 4-6 months out to five years, and our thoracic surgeons tend to continue annual follow-up after that. CBC and chemistries at each visit. NCCN points out that the value of CEA is unknown, but we tend to check them. Imaging...
Do you perform PEEP titration while patients are proned?
Once a patient is proned- we don't use the PEEP: FIO2 ratio tables because you want to continue optimal recruitment. So we monitor driving pressures and maintain PEEP for optimal driving pressures. Also remember as the chest wall compliance decreases with proning, for a given plateau pressure, your ...
What patient factors, if any, would lead you to extubate a patient at high risk of extubation failure to AVAPS rather than BIPAP?
Unless a patient used AVAPS/iVAPS support prior to intubation and is returning to baseline, I discourage our team from using volume-targeted pressure support in acute situations. Although the idea of having a volume target is attractive, there are many opportunities in the acute setting for unexpect...
How would you manage asymptomatic osseous sarcoidosis of the lumbar spine without any other systemic involvement?
Some patients with sarcoidosis are found to have bone-related abnormalities. These are frequently incidental findings often detected as a phantom abnormality on PET or MR scan without corresponding X-ray or CT abnormality; this suggests they are foci of inflammation localized within bone marrow and ...
What is your protocol to starting/stopping glucocorticoid replacement in Cushing disease patients after their transsphenoidal resection surgery?
The initiation of glucocorticoid treatment post-transsphenoidal surgery in patients with Cushing's disease varies across different medical practices. Dr. Fleseriu's paper provides a comprehensive review of Cushing's disease management, offering valuable insights (Fleseriu et al., PMID 34687601). Typ...
What is your approach to working up diarrhea in an immunocompromised patient?
Tough question and very common in clinical and research management. The approach is going to mirror any new complaint and start with a history. Diarrhea means many things to many patients/clinical trial subjects, so characterizing duration, frequency in a day, nocturnal events (diarrhea that occurs ...
How do you assess the use of Heimlich valves for patients who present with persistent air leaks?
I would do it for patients who have a persistent air leak and can tolerate water seal (lung is up on xray on water seal but chest tube has air leak).
How do you define an adequate EBUS when staging NSCLC?
Important question. There is a high degree of variability in the diagnostic performance of EBUS based pretest probability of disease, physician experience and skill, quality control, and evaluation skills of the cytopathologist. Nice consensus guidelines from CHEST was published a few years back det...
Is there a role for hydroxychloroquine for secondary prevention in patients with APS without SLE?
There are no prospective trials to answer this question. In one cross-sectional study (Erkan et al., PMID 12154210) there was a suggestion of a protective effect of hydroxychloroquine. However, patients were also on aspirin and it may be difficult to sort out which of these agents had the protective...