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?
I would use DAPT for three months after the stroke. I do not see evidence for either anticoagulation or protracted DAPT for ICAD.
At what point should aspirin therapy for stable cardiovascular disease be discontinued in patients with a diagnosis of chronic cerebral microbleeds or possible Cerebral Amyloid Angiopathy?
I would continue low aspirin indefinitely.
Do you recommend routine ophthalmologic exam for all patients with hypervirulent Klebsiella pneumoniae bacteremia?
The incidence of endogenous endophthalmitis due to Klebsiella bacteremia, especially due to hypervirulent K. pneumoniae strains, has been increasing. Klebsiella endophthalmitis is associated with poor visual outcomes Several studies, primarily from Asia, have described risk factors for developing en...
How soon after an end stage kidney disease patient receives a MRI study with gadolinium contrast do you perform their next hemodialysis session?
Very contentious question. But as an author of the NKF and ARA position paper on this, I would follow our advice, no need to dialyze immediately after, but try to time the study with the next dialysis.Weinreb et al., PMID 33170103ASN Communities (for ASN members) had a VERY LONG post on this general...
What treatment options would you consider for a young patient with limited mobility, low bone mass and multiple vertebral compression fractures who is on dialysis for advanced kidney disease?
There are a lot of variables to this question. I would worry that the person may have a variant of OI (osteogenesis imperfecta) or some other collage problem and then add renal failure to the mix. I would try to establish the causes of each problem first such as steroid induced bone disease or a bon...
Following left main bifurcation stenting, do you routinely proceed with kissing balloon inflation of the side branch, either LCx or LAD?
It depends on the technique used; most crush based techniques require kissing balloon inflation.
Would you consider adding or switching to pirfenidone for a patient with progressing UIP (based on imaging and PFTs) who is currently on nintedanib?
Yes, I would consider it. There's some recent literature addressing this, which indicates switching may be associated with disease amelioration. Why might it work? Not super clear, perhaps biologic differences or maybe driven by better compliance. Smarter people than me could probably speak to the r...
In patients with sicca symptoms and positive SSA/SSB how often do you perform other diagnostic testing such as salivary gland ultrasound, biopsy, Shirmers, ocular staining, stimulated salivary flow, etc?
In patients with sicca symptoms and positive SSA antibodies, I always try to confirm that they have objective evidence of dryness/gland involvement. This is because patients can say they have dry eye and/or dry mouth yet not have this bear out on objective testing (Bezzina et al., PMID 27992710, Rip...
How can hepatic venous pressure gradients in patients with cirrhosis be used to differentiate between cardiac cirrhosis and portopulmonary hypertension?
HVPG is a measure that quantifies the increase in sinusoidal resistance to blood flow and can be obtained in a minimally invasive way compared to portal venous sampling directly which may be more invasive. HVPG is the pressure difference between hepatic vein wedge pressure (HVWP) & hepatic vein free...
What is the importance of finding a positive titer for TS-HDS and what treatment would be advised for these patients?
TS-HDS antibodies were first described by investigators from Washington University in St. Louis (2003) in five patients with painful sensory axonal neuropathy [1]. Further studies by the same group indicated that TS-HDS antibodies were associated with prominent neuropathic pain in the upper extremit...