Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the use of endothelin receptor antagonists in patients with scleroderma renal crisis and hypertension refractory to maximum ACE inhibition and calcium channel blockers?
There is pathologic evidence of endothelin being increased in the renal biopsies of patients with scleroderma renal crisis. There has been one small prospective open study where endothelin receptor antagonists were used in addition to ACE inhibitors in some refractory patients and compared to histor...
How do you manage drug-induced thrombocytopenia when the implicated drug is essential?
I feel obliged to answer this one as a question of medical sociology as much as a direct medical question, because "essentialness" is nearly always in the eye of the beholder, and I have not personally been in the position of the hematologist who has to confront this question with an interventional ...
When do you consider plasma exchange for multiorgan failure in a patient with sickle cell disease?
The first choice for treating multiorgan failure in sickle cell disease is exchange transfusion that should be started as soon as possible. Sometimes the clinical and hematologic features of sickle cell multiorgan failure resemble and overlap those of thrombotic microangiopathies like TTP. Also, tru...
Do you recommend the use of endobronchial valves in the management of patients with spontaneous pneumothorax with persistent air leak?
Patients with primary spontaneous pneumothorax and persistent air leak or recurrent pneumothorax should be considered for surgery (typically VATS) with bleb resection and pleurodesis in order to prevent a recurrence. I believe bronchial valves in this setting have a little role since they are not de...
Do you employ the use of external chest compression with sandbags in the management of patients with severe ARDS who are not candidates for proning?
The short answer is while there is a physiologic rationale to support the beneficial effects of supine chest wall compression, the best method and clinical impact of such maneuvers have not been studied. In addition, there may be potential untoward consequences to sustained chest wall compression th...
For patients receiving outpatient venetoclax/azacitidine who develop profound neutropenia with ANC <200, do you admit for monitoring during the nadir in the absence of fever?
I don't think I would admit these patients. My recommendation would be to monitor temperature daily or feel febrile and let the clinic know if they have any symptoms of localizing infection. The NCCN and IDSA guidelines talk that only neutropenic patients with fever, even amongst those who have the ...
Do you recommend hydroxyurea in patients with sickle cell disease with hereditary persistence of fetal hemoglobin who have recurrent vaso-occlusive crises requiring hospital admission?
It’s complicated. Patients with sickle cell-HPFH that is due to deletion of the beta-globin gene usually have 30% HbF spread nearly evenly among their red cells (pancellular), and as a result, have almost normal hematology and rarely have sickle vasoocclusive events. They do not require treatment. (...
What protocols or safeguards do you implement if bed bugs are found on a patient or their belongings while on the treatment table or near equipment?
Typically once a bedbug is identified, the patient is brought directly into our inpatient holding bay so that there is limited time to contaminate common areas of the department. Therapists do utilize contact precautions including knee high shoe covers. We then have our hospital facilities team trea...
Are there situations where you would start treatment for cardiac amyloid in a patient with amyloid seen on biopsy, but still pending mass spectrometry results?
I do not think of treating cardiac amyloid without the results of mass spec. You really need to know what type of amyloid you are dealing with.
How do you manage rectal or bowel perforation from interstitial brachytherapy needles?
One additional step I take other than the one highlighted is at the time of CT simulation if I notice that, I would pull those needles out either completely or to the point they are not into the wall of OARs.