Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach when cryptococcus serum or CSF antigen titers do not change despite treatment in HIV-positive patients with cryptococcal meningitis or invasive disease, but there is clinical improvement and cultures remain negative?
While cryptococcal antigen is an excellent diagnostic marker for this infection, with excellent sensitivity and specificity, it is not reliable for tracking response to therapy. An initially high CSF antigen level has been identified as a sign of poor prognosis in patients with AIDS, but multiple st...
What is your approach to managing post-operative dysphagia following C-spine surgery?
Dysphagia is relatively common after anterior C-spine surgery. (recently estimated at 10%, Shimizu et al., PMID 40461647). While I have less rigorous personal data, anecdotally, I agree with the conclusions of the authors that postoperative pain is a significant predictor. While I typically defer in...
What is the optimal frequency and duration of post-operative radiological surveillance following resection of a solitary fibrous tumor?
Partly depends on the subset of SFT. The classic variant is low-grade, indolent clinical behavior and can recur late (several years later) requiring (maybe less frequent) but long-term follow-up for 10 years or even beyond. The malignant SFTs have a shorter natural history and typical sarcoma follow...
Is there a role for DOAC use for patients with unprovoked PE, that have had recent sleeve gastrectomy with duodenal bypass?
Alterations in the gastrointestinal (GI) tract following bariatric surgery, as well as altered or reduced oral intake, have the potential to impair the absorption of both DOACs and VKAs in the acute setting. DOACs are absorbed in the upper GI tract, which is altered by the most common bariatric surg...
What is the role of surveillance imaging after first line therapy in patients with aggressive lymphomas?
Most relapses from complete remission in patients with diffuse large B-cell lymphoma are symptomatic. I am aware of no evidence that surveillance leads to the diagnosis of asymptomatic relapses that are more likely to respond to salvage therapy. My own concern about frequent surveillance is the adve...
Would you consider PPM implantation for patients during their hospital stay following TAVR if they were to develop lengthening PR intervals and widening LBBB QRS duration exceeding 150ms afterwards?
Would do an EP study to guide me further.
How do you identify the subset of heart failure patients who are likely to benefit from cardiac resynchronization therapy in the setting of an RBBB pattern?
There are no good criteria to delineate which patients with RBBB will benefit from traditional CRT. The best contemporary strategy is to consider CRT if a patient has an RBBB > 150 ms, an atypical morphology (suggesting an underlying delay in the LBBB or an IVCD), and Class III-IV HF symptoms. One m...
What is your approach to optimizing pre-operative hemoglobin in patients with sickle cell disease?
Unfortunately, I am not aware of a more comprehensive document than the ASH guidelines. These are what I use to define my default management strategy, often in coordination with our dedicated hematology consult subspecialist service.
How would you evaluate a patient with an isolated high RBC count but with a normal hemoglobin and hematocrit?
My first question would be, how long has the elevated red cell count been present? I ask this because, in a study of 10,000 individuals, erythrocytosis was initially found in 88 but after a year only 11 still had this finding (Ruggeri et al., PMID 13679323). If therefore, the observation is recent, ...
What workup do you recommend for otherwise healthy migraine patients that develop dizziness with episodes?
The workup should exclude other potential causes of vertigo including CNS disorders, and Meniere's disease, with neurology examination, MRI brain, videonystagmography, or electronystagmography. An article also evaluated vestibular migraine versus migraine without vertigo and found in several studies...