Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For inpatient treatment of lymphoma and ALL, can rituximab be delayed?
Although I am not aware of published data on this issue, at least for patient receiving DA-R-EPOCH, I have learned that it is common practice to delay the day 1 rituximab because of the reimbursement issue you refer to. I don't think the effect of this has been studies systematically, but i'm not aw...
How would you manage a patient with anal squamous cell carcinoma and 5 FU induced coronary vasospasm 36 hours after starting definitive chemoradiation?
I would seek the assistance of an oncocardiologist, if available. Did the patient develop EKG changes? Troponin leak? For coronary vasospasm induced by 5FU, there is a range of severity and risk. Given that this patient only requires a second dose of 5FU, I would see if there were any possibility of...
How do you manage a hemorrhage from a cavernous malformation following SRS?
As the evidence for benefit or irradiating AOVMs is circumstantial at best, I am referred quite a few. Bleeding after treatment would be managed on a case-by-case basis but would often be expectant and would not be influenced by the prior SRS. I would personally not re-treat an AOVM — especially the...
How would you treat a young patient with symptomatic Rosai-Dorfman disease who has recurrent, life-threatening pericardial and pleural effusions?
Rosai-Dorfman disease is the most tricky one of the top 3 histiocytosis (ECD, LCH, and RDD). It can behave as benign or as an aggressive disease. Given the rarity of the disease, there are no great prospective studies to guide optimal treatments. First-line treatment includes prednisone or other imm...
Would you recommend anticoagulation for patients with partial false lumen thrombosis in type B aortic dissection?
Type B aortic dissections are generally managed by vascular surgeons using endovascular techniques or surgery. Anticoagulation is not recommended for partial false lumen thrombosis. If complications arise such as downstream occlusion of vessels due to thrombosis or embolism, urgent surgical evaluati...
How would you manage newly diagnosed spinal cord compression presenting with paraplegia without tissue confirmation?
Would you start a patient with sickle cell disease and COVID-19 on prophylactic anticoagulation?
What is the optimal VTE prophylaxis for hospitalized patients with COVID-19?
At the moment, my personal recommendation, in general, is to follow the ASH guidelines. If the patient has cancer and other major comorbidities along with COVID-19, a discussion is warranted around adjusting the dose of anticoagulation to the presumed risk of VTE in the individual patient, understan...
What is the transfusion management of a sickle cell patient during pregnancy?
Prophylaxis: There is an ongoing trial in transfusion management in pregnancy, comparing prophylactic red cell exchange to a target HbS or SC < 30% compared to transfusion only when clinically indicated. Interestingly, it does not specify a Hct target. Until that trial is done, I would follow the AS...
How do you counsel patients regarding initiation of total parenteral nutrition (TPN) with malignant small bowel obstruction?
The answer we give to this question symbolizes how we think about treatments to be offered to a patient near the end of life. Thus, these answers often say as much about us as they do about our patients or medical science. In my experience, conversations around things like TPN toward the end of lif...