Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When is it considered inappropriate to omit pathological mediastinal lymph node staging for non-small cell lung cancer?
This is a very good question often debated by thoracic radiation oncologists with their thoracic surgery colleagues and can get complicated. The best way to look at it, in my opinion, is to understand the sensitivity and specificity of FDG PET/CT to detect true mediastinal nodal disease. For example...
Have you applied the POET trial to clinical practice?
I do transition to oral therapy after clinical stability, resolution of systemic inflammatory response and blood culture negativity have been achieved. I have long operated on the principle that it doesn’t matter how (IV or oral administration) the antibiotic gets into the bloodstream as long as it ...
Would you recommend genetic testing to determine if there is a potential underlying primary process in a patient with congenital solitary kidney who is presumed to have secondary FSGS?
I do recommend genetic testing more frequently especially at our institution in which the cost to the patient is minimal to none. I would imagine very rarely one finds a positive genetic test result but one never knows what we find until we do the testing.
When do you re-image patients with a diagnosis of venous sinus thrombosis?
My practice is to perform early reimaging, typically at around 2 weeks, before transitioning from parenteral anticoagulation to oral anticoagulation. This early reassessment is important as recanalization processes begin early and are linked to clinical outcomes. Subsequent imaging at 6 months is al...
Which patients presenting with spontaneous ICH should be considered for a diagnostic cerebral angiogram/DSA?
Given the ease of obtaining CT angiograms, the majority of patients both with and without a history of hypertension are routinely getting CTA's. This has truly led to a minimization of the need for diagnostic cerebral angiograms. While the diagnostic performance of noninvasive neuroimaging is not cl...
How do you prescribe ketamine for treatment of refractory status epilepticus, and what is its efficacy?
For cases of RSE, I usually turn to ketamine if I encounter hypotension with propofol or if I'm not achieving the desired EEG response. My typical approach involves administering a 100 mg bolus followed by a continuous infusion of 100 mg/hr. For more detailed information, you can refer to this artic...
Is there still a role for direct laryngoscopy in the intubation of patients in the ICU?
I believe you have to be proficient in many techniques in case you need alternatives when performing a procedure. This applies to DL. Video intubation has facilitated intubation greatly but the technique is different and if it fails the default is DL.
How do you manage diarrhea in a patient with CTD-ILD on MMF who was recently started on full dose nintedanib?
It is important to keep in mind that immunomodulator therapy is also frequently associated with gi toxicity (MMF, methotrexate, leflunomide, azathioprine, etc.). Given this, it is important to begin one therapy at a time in order to mitigate side effects and do understand which agent is responsible....
Do you prefer monitoring creatinine over cystatin C levels in patients with lymphoma and chronic kidney disease given the potential for cystatin C levels to be increased with certain malignancies?
My default is to monitor creatinine, not cystatin C, in all patients with malignancies except: if patients have had weight loss and down-trending creatinine, patients are at eGFR cutoffs for chemotherapy drug dosing, leading to concern for potential over/under-dosing, there is concern for pseudo-AKI...
Do you continue to prone patients with severe ARDS after initiation of VV-ECMO?
Not routinely - although we have occasionally proned VV ECMO patients at our center. Reasons for not proning include: Cannula dislodgement/displacement risk (although Roca et al, PMID 34461971 reviews the literature on proning with VV ECMO and the risk of major line complications is small). Generall...