Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How does your hospital approach the use of insulin pumps for admitted patients?
Patients using insulin pumps are only on rapid-acting insulin, so that any interruption in the use of the pump requires them to switch to a combination of basal insulin and rapid-acting insulin. This is hard to do in a controlled outpatient setting (for example, technical failure of the pump), but v...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
How would you manage an elderly patient with type 3 achalasia who previously underwent POEM and has recurrent dysphagia, high Eckardt score, and dilated esophagus concerning for blown-out myotomy on esophagram?
This is a complex clinical scenario which requires a multi-disciplinary approach at an expert center. One of the main goals is to decipher why the patient is still having symptoms. Is the patient is having symptoms due to persistent achalasia or due to the blown out myotomy. You can make this distin...
Is there any utility to trending Histoplasma serology titers to guide duration of therapy or treatment response for pulmonary histoplasmosis with negative urine antigen?
Serology unfortunately is not useful to monitor response to therapy as the fall in titers is often very slow. In immunocompetent individuals, titers will often take a few years to show a significant drop in the antibody titer after successful treatment. The treatment duration should be guided by the...
Does a low serofast RPR titer (such as 1:1 or 1:2) in the setting of a remote history of appropriately treated latent syphilis in a patient with now uveitis of yet unknown etiology referred from ophthalmology for possible ocular syphilis make a diagnosis of ocular syphilis less likely?
I err on the side of offering empiric treatment. As syphilis rates have risen over the past 20 years, so has the incidence of syphilitic uveitis (Mir et al., PMID 37991790), and the question posed, therefore, represents a not uncommonly encountered conundrum for infectious disease consultants. Syphi...
Would you recommend administering IV amino acids prior to cardiac surgery with cardiopulmonary bypass, given recent trial findings of improved AKI rates but no significant difference in kidney-replacement therapy with IV amino acids?
The trial by Landoni et al., PMID 38865168 in the August NEJM examined the effect of an amino acid infusion (2g/kg/day) in patient undergoing cardiac bypass surgery. They found a reduction in post-op AKI, but no change in the need for dialysis or mortality. Although this was a large (>3500 subjects)...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
How do you manage neurocognitive decline associated with chemotherapy (i.e. chemo brain)?
I agree with @Dr. First Last's detailed response. Practically speaking, I would also add that it is important to listen and validate your patient's concerns and respond to their frustration and sense of loss. A diagnostic evaluation will not only help you and your patient discover or 'rule out' othe...
What factors influence your decision between guidewire exchange versus removal and replacement through a new tunnel tract for patients with tunneled hemodialysis catheter mechanical failure?
Mechanical failure of a tunneled dialysis catheter (TDC) could be from catheter cuff extrusion form the exit site, catheter thrombosis or a fibrin sheath. In all three scenarios I prefer guidewire exchange rather than removal and replacement of the TDC. Removal and replacement are much more invasive...