Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Which biomarkers or diagnostic tools do you prioritize to support the decision to start antifungal treatment in septic patients with no clear source of infection but at high risk for fungal infections?
In general terms we do not use biomarkers to decide to start antifungals in a septic patient. We use them to confirm or rule out the infection once the antifungals were started based on clinical suspicion/presentation. BDG in particular has very good negative predictive value for candidemia, but due...
What is your strategy for managing immunosuppression in patients with a kidney transplant who develop metastatic cancer?
This is a difficult situation. I presume this question refers to cancers for which there is no option of cure. We always discuss the goals of care and review with the patient and their treating oncologist what the prognosis might be. If chemotherapy or check-point inhibitor treatment is planned we ...
What are some potential etiologies to consider for isolated, mildly elevated BNP levels with normal TTE findings in an asymptomatic, elderly patient?
BNP and pro-BNP both increase with age, especially in women, and must therefore be interpreted in that context. Pro-BNP less than 300 pg/mL indicates low likelihood for acute heart failure at all ages (though there are exceptions). The recommended age-based thresholds for diagnosing heart failure/vo...
Do you monitor CBCs to assess for drug toxicity in patients on nintedanib?
Not typically. I've never been advised to check these, but it's worth re-examining whether it's worthwhile. Looking at the side effect profile in INBUILD and INPULSIS doesn't reveal any major cytopenias. It doesn't appear to be on the FDA prescription information, either. I think this question arise...
How would you manage a patient with sickle cell disease who is infected with COVID-19?
We have limited knowledge about this management. The Sickle Cell Disease Association of America's Medical and Research Advisory Committee has issued a provider advisory. Also, Dr. Julie Paniepento has created a registry that can be viewed in real time here: https://covidsicklecell.org/ In general, t...
For pregnant patients in their first trimester presenting with acute MI with plan for emergent angiogram, who then subsequently have resolution of chest pain and EKG changes following initiation of heparin gtt, DAPT, would you still consider proceeding with LHC or treat medically with presumptive diagnosis of SCAD?
Great question and a highly debatable topic. I would consider a coronary angiogram to define the coronary anatomy as there are many differentials for pregnancy-associated acute myocardial infarction with ST elevation and treatment can differ accordingly. A conservative approach is acceptable for a l...
Would you start once-weekly tirzepatide over once daily basal insulin in a patient with Type 2 diabetes with inadequate control on oral antihyperglycemia drugs?
The issue examined in the paper cited of whether insulin or GLP-1RA is a better strategy in the setting of inadequate control of T2D was a hot question in the first part of this century but has been examined repeatedly and is now codified in global guidelines -- GLP-1RA should be used before insulin...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
Do you recommend parathyroid imaging testing for patients with recurrent nephrolithiasis who are incidentally found to have an elevated PTH but who do not have hypercalciuria, hypercalcemia, hypovitaminosis D, or chronic kidney disease?
Yes, but with caveats. The “yes” is because hyperparathyroidism is a surgically curable disease if done by an experienced parathyroid surgeon. The caveat is if previous stone analyses have not shown a substantial calcium phosphate component, the stone formation may be due to other causes and unaffec...
How do you differentiate demoralization from depression during cancer treatment?
Certainly a key question in all referrals for "depression" in psycho-oncology. The two syndromes have areas of overlap and are not mutually exclusive. Clinical depression in cancer looks much like it would in any other context, though non-specific physical symptoms that can be caused by the cancer/t...