Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are contact precautions effective at preventing MRSA transmission in healthcare settings?
I have a major axe to grind here. Whenever this has been looked at it seems that the answer is that, outside of an outbreak situation for example, so long as people wash their hands, this adds nothing but waste of medical equipment. See the following articles: CID review: Diekema et al., PMID 377385...
How do you approach the diagnosis of erythronychia?
Erythronychia has a broad differential including inflammatory diseases (lichen planus), infectious diseases (verruca), and benign (onychopapilloma, glomus tumor), and malignant tumors (SCC, amelanotic melanoma). I approach erythronychia with history and physical examination including measuring width...
In a life-time non-smoker with stage IV lung adenocarcinoma presenting in visceral crisis, what therapy would you recommend to avoid organ failure while awaiting mutational status?
I would offer cytotoxic platinum doublet chemotherapy and omit immunotherapy based on emerging data that TKI adverse events are often worse after prior immunotherapy exposure (Calles et al., PMID 32421452). The choice and dose of cytotoxic doublet will depend on the individual circumstances of each ...
Are there concerns with using sulfasalazine in SLE?
A very practical question:1. Yes, there is a concern theoretically; but you can use SSZ in lupus patients in certain circumstances.Sulfonamides are divided up into antibiotic (abx) sulfonamides (like trimethoprim-sulfamethoxazole, TMP-SMX) and non-abx sulfonamides (e.g. furosemide, hydrochlorothiazi...
How do you re-stratify patients with a primary prevention ICD in need of a generator change if their LVEF has improved to >40% and they have not previously required any device therapies?
This is an important question on which there remains a lack of consensus. We had tried to address this through an observational study which was published a few years back:(Appropriateness of primary prevention implantable cardioverter-defibrillators at the time of generator replacement: are indicati...
How do you approach the workup of transverse myelitis without any abnormality on spine MRI?
If you are highly suspecting TM on clinical features, and other etiologies seem unlikely, then consider LP, checking labs (autoimmune, demyelinating, infectious, metabolic, etc), starting immunotherapy (if infection is unlikely, maybe check with Infectious Disease on that decision), and then in a fe...
How would you approach the work up of SLE in a patient over 80 years old?
Elderly onset lupus is uncommon and in the past twenty-five years has been reported to occur in as few as 6% of patients to as many as 19% of patients with the diagnosis of lupus. Typical clinical presentations tend to include arthritis/arthralgias, fever, weight loss, lymphadenopathy, serositis, si...
What is your approach to considering geriatric patients for complex PCI given their overall frailty and increased risk of complications such as bleeding and stroke?
I would do everything I could with respect to medical and lifestyle therapy for such a patient. They are at very high risk for a bad outcome in the cath lab.
When do you pursue interventional treatments in a lung transplant patient with anastomotic dehiscence complicated by a bronchopleural fistula?
Very small areas of dehiscence are typically managed conservatively with serial bronchoscopy for observation. However, for larger areas of dehiscence associated with a higher risk of mediastinal or pleural infection, we typically opt for mechanical debridement and airway stent placement to cover the...
For bone metastases requiring surgical stabilization, what time interval from the date of surgery do you use for post-op radiation?
Generally, the surgical stabilization minimizes the capability of short-term catastrophe in (like path fracture), what I presume to be a long bone that has undergone surgical stabilization. I'd probably want to give a few days just to maximize local wound healing but starting sometime, maybe 1-2 wee...