Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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 agree. tPA is not a contraindication to the later prescription of dual antiplatelet therapy. I do not see a definite answer to the question of 21 days versus 90 days, the CHANCE trial (Wang et al., PMID 23803136) supports 21 days and the POINT trial (Johnston et al., PMID 29766750) 90 days. ...
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...
Do you start anticoagulation in a patient with infective endocarditis who also has atrial fibrillation and stroke?
In the acute phase, no. You have to get CTA or MRI/MRA with contrast to evaluate for hemorrhagic risk associated with mycotic aneurysms. Even without aneurysms, there is an increased risk of hemorrhage. I normally recommend aspirin in atrial fibrillation patients while the infection is being treated...
Is angioedema secondary to IV tPA considered an absolute contraindication for tPA in future?
In short, no. In general, the only absolute contraindications to alteplase and other forms of tPA are active bleeding or situations that could result in active uncontrollable bleeding; all other considerations are relative. Hemi-orolingual angioedema is thought to arise associated with activation of...
When do you start anticoagulation in a patient with cardioembolic CVA secondary to new onset atrial fibrillation with hemorrhagic conversion?
Those are great questions and there is no right answer. My general practice is to delay anticoagulation beyond the standard 3-14 days initiation period when there is hemorrhage. I would wait longer if the hemorrhage is parenchymal as opposed to petechial but in both cases, I performed follow up scan...
In what subset of traumatic brain injury/concussion patients would you consider use of N-Acetyl Cysteine?
There are some reports that N-Acetyl Cysteine (NAC) may help the patient with TBI for behavioral recovery and it has neuroprotective effects. I also used NAC and Alpha lipoic acid in patients with post-chemotherapy neuropathy as antioxidants. There are limited studies on how effective they are but t...
How do you approach the workup of a patient with incidentally found pachymeningitis?
In general, when we think about the meninges, we consider the leptomeninges and the pachymeninges separately, though many of the disorders of one can also cause disease in the other. We also consider whether the pachymeningitis is focal and nodular or diffuse. Common causes of pachymeningitis are in...