Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you typically screen patients for antiphospholipid antibodies in autoimmune diseases besides lupus in the absence of a clotting event?
I would check antiphospholipid antibodies (APLAs) in a few situations in the absence of thrombotic events: 1. In someone with other APS manifestations: Obstetrical complications (especially) APL nephropathy noted on renal bx Unexplained adrenal hemorrhage/microthrombosis Non-infectious endocardial v...
What is your approach to counseling a patient with stable but severe multivessel coronary disease if the patient does not wish to undergo bypass surgery?
The question assumes that a stable patient with multivessel disease would do better with bypass surgery. If the ejection fraction is less than 35% then the long-term outcome from the STITCH trial showed a reduction in mortality. There is no comparable data for angioplasty. If the patient refuses sur...
What are your next steps when managing patients with suspected Gitelman syndrome for whom genetic testing reveals variants of uncertain significance or novel mutations not well characterized?
If the patient had a clinical syndrome that fit the Gitelman phenotype I would totally treating as such.
How do you approach the treatment of drug-induced thrombotic microangiopathy?
Typically, transplant-related TMA is due to sirolimus, tacrolimus, cyclosporine, or some combination of those drugs. The first step is to reduce the dose. Often keeping the drug at the lower end of the therapeutic level, the TMA will resolve or ameliorate. If, for instance, sirol and tac are used to...
Which factors would prompt empirical lead extraction in bacteremic patients without TEE evidence of lead vegetation?
My point of view is to have a very low threshold to extract a device where infection is likely. The presence or absence of lead vegetation may be a bit misleading as lead thrombi are not uncommon. I think the presence of a thrombus may make us feel more resolute in the removal plan though this may b...
How do you approach treating idiopathic aortitis?
Before classifying a patient as ‘idiopathic’ or ‘clinically isolated aortitis’ (CIA), one must carefully consider that the aortitis may be a manifestation of a systemic condition, particularly giant cell arteritis or Takayasu arteritis. Other systemic diseases associated with aortitis include IgG4-...
What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?
It is a fair question that we don't have a solid evidence-based answer for. I agree that the SAMMPRIS trial was driven by events within the first 30 days, although this was primarily driven by procedure-related events in the stented group. We do know that intracranial athero (ICAS) risk of stroke re...
What is the right approach in terms of GDMT and device consideration for patients with intermittent LBBB (QRS duration exceeding 150ms) and HFrEF?
I would not consider an intermittent left bundle as criteria for BiV pacing. I would actually not consider it in my assessment of heart failure gdmt or device therapy in isolation, whatsoever.
When can abdominal surgery be safely performed for presumptive ovarian cancer in a patient with recent pulmonary emboli?
In general, the standard approach is to try to wait as long as possible after the thrombotic event, at the very least three months. This may not be possible, we then reduce that time interval to one month. Given the urgent nature of the surgical intervention, one approach is to wait one month and co...
Do you diagnose obstruction by the criteria of FEV1/FVC < 70% or < LLN?
Using lower limit of normal for FEV1/FVC ratio may reduce misclassification of airway obstruction but despite years of discussion and arguments it remains unclear whether it is a better approach. The simplicity of the fixed ratio approach to me remains a very important consideration and it is the ap...