Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you preferentially avoid use of piperacillin-tazobactam for empiric anti-pseudomonal coverage in hospitalized patients due to risk of nephrotoxicity?
The bulk of published data indicates that the onset of nephrotoxicity in patients receiving piperacillin-tazobactam plus vancomycin seldom occurs before 3 days of the combination. Thus, I do not object to initiation of this combination empiric therapy, but, as in all cases, therapy must be reevaluat...
What would be your threshold to recommend TEE guided DCCV in a patient who has remained in atrial fibrillation in the post-operative period following CABG, who has achieved adequate amiodarone loading dose?
If not anticoagulated for a sufficient period of time, TEE would be mandatory prior to electrical cardioversion.
How do you approach RA management in a patient who develops a new solid tumor while on therapy?
Risk-benefit ratios need to be individually assessed. There are several aspects to take into account: Choice of DMARD - Data on impact of various DMARDS on cancer recurrence or progression is scarce, especially for patients with active cancer. In general, there are few concerns for conventional DMA...
Would you recommend TNK or DAPT in patients with stroke-like symptoms and NIHSS less than 5 presenting within 4.5 hours?
I agree with Dr. @Dr. First Last. The decision in patients with minor stroke rests on whether the symptoms are disabling, which in general, is based on a discussion with the patient and their family to understand how the deficit could impact the patient's career or hobbies. For disabling deficit, I ...
In what clinical settings is acute ICH clot removal recommended?
Clot removal should be performed when there is a cerebellar hemorrhage with brainstem compression and/or hydrocephalus. Clot removal can be considered as a life saving measure if there is neurologic deterioration, midline shift, or depressed consciousness. There is still uncertainty about clot remov...
What is your preferred method for confirming the diagnosis of primary aldosteronism in a patient with an elevated plasma aldosterone to renin ratio?
The endocrine guidelines on primary aldo diagnosis (1) allow for 3 confirmatory tests: 24-hour urine, fludrocortisone suppression testing, and response to saline infusion. At UAB, we use the 24-hour urine collection. Most of our patients do not need additional salt loading during the 24-hour collect...
Which medications do you deem necessary to stop prior to measuring plasma renin and plasma aldosterone when evaluating a patient for possible primary aldosteronism?
The most important medications to stop before checking renin and aldo levels are spironolactone, amiloride, triamterene, finerenone, and eplerenone. Ideally, patients should be off these meds for at least 6 weeks before testing. A pathologic primary aldo can be detected while taking beta blockers or...
How do you approach treatment of a patient with active RA and a history of Lynch Syndrome?
The presence of hereditary polyposis coli and its predisposition to colon cancer should have little effect on the management of RA. Available data indicate that methotrexate has at best a neutral effect on predisposition to malignancy. There are data to suggest that the combination of methotrexate a...
Would you ever consider oral doxycycline for treatment of either gram-negative or gram-positive uncomplicated bacteremia?
I would not consider this a first or even second-line option due to the poor serum levels that are achieved. I supposed that this could be used for "mop up" therapy, but in such cases, it's almost as if you are using the doxy to treat yourself rather than the patient.
How does your approach to subsegmental PE differ from segmental PE both diagnostically and therapeutically?
My approach to subsegmental PE and segmental PE generally tends to be very similar. I am aware of the CHEST guidelines which indicate patients can safely be observed with subsegmental PE, but like a recent study showed (Rouleau et al., PMID 37531107), uptake of these guidelines is slow and many pati...