Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For stroke patients with ablated paroxysmal atrial fibrillation without known recurrence and ICAD, would you recommend dual antiplatelet therapy or anticoagulation with or without an antiplatelet agent?
Ablation treats cardiopulmonary symptoms, but it has not been adequately tested against anticoagulation for AFib-related stroke. Anecdotally, at least once a month, I will see a patient with an acute embolic-appearing stroke after their cardiologist has stopped their anticoagulation because they wer...
Should the use of avacopan be limited to those patients at increased risk of steroid toxicity given the anticipated high cost of this medication?
Once Avacopan is available for clinical use in the treatment of patients with AAV, providers will need to carefully weigh risks and benefits of the medication while considering other factors including cost.The ADVOCATE trial used a novel glucocorticoid toxicity index that captures common GC-related ...
How do you approach initiating a deprescribing conversation about a long-standing benzodiazepine in an older adult who has been on a stable dose for years and reports no side effects?
First, I try to understand what symptoms led to the initiation of the benzodiazepine, which can help me identify whether there is a safer alternative treatment. Then I make sure people understand why we want them to come off the benzodiazepine in the first place, since this is not common knowledge (...
How do you evaluate persistent resting sinus tachycardia (heart rate >100 bpm) in a hospitalized patient whose acute illness has otherwise stabilized?
This is a great question and something that we see rather frequently in the hospital. 2 guiding principles to frame this question: Sinus tachycardia (ST) is a symptom, not a diagnosis. It's a physiological response to an underlying condition. Which means we need to diagnose the condition, not focus ...
How do you use NT-proBNP in patients with chronic kidney disease or end-stage kidney disease, given that these conditions can affect NT-proBNP levels?
NT-proBNP is most useful for (a) diagnostic uncertainty in patients who present with dyspnea, and (b) prognostication in heart failure. It is released as a result of ventricular wall stress. In CKD, the clearance of NT-proBNP is impaired, leading to elevated levels. In late-stage CKD and ESRD, volum...
Would you consider amiodarone for the treatment of atrial fibrillation with RVR in patients who cannot tolerate beta blockers but have a high CHA2DS2-VASc score and are not on anticoagulation?
We typically do not due to risk of chemical cardioversion and precipitating an embolism.
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
What strategies do you find helpful in advanced care planning with patients/families who are very "miracle" centered?
Hope for the miracle yourself! Broaden: “Are there any other things you are hoping for?” Hope for the best, prepare for the worst: “I see how much you want a miracle. I wonder if we can talk about what we should do if this doesn’t happen.” Consider involving a religious leader if relevant.
What is the expected timeframe for the development of radiation myelitis and therapies that have helped with neurologic symptoms?
The incidence and the timeframe of the development of radiation myelopathy are influenced by total radiation dose, radiation dose per fraction, time between courses of radiation, and associated chemotherapy or immunotherapy. Older age, the presence of diabetes, and previous exposure to radiation are...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...