Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach the management of aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?
In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...
Is there a role for routine EEG in the diagnostic evaluation of critically ill comatose patients or should these patients always receive long-term continuous video EEG monitoring?
We looked into this and found that in a non-comatose patient with no history of clinical seizures, the lack of epileptiform abnormalities on initial 30 minutes of EEG recording is associated with <5% risk for electrographic seizures suggesting that a routine EEG can be sufficient in that group (Stru...
Do you think repeated routine EEG is sufficient for cardiac arrest patients or should we be always using continuous EEG?
For most patients with cardiac arrest, cEEG has not been shown to offer improved outcomes over serial routine EEGs. In cases where there are EEG patterns that suggest seizures may be occurring, such as rhythmic or periodic patterns other than low-frequency GPDs, or repetitive evolving patterns, we t...
Can the tracheostomy be reversed after completion of chemoradiation for laryngeal cancers?
Yes, if there has been a CR. Wait 3 months. PET. If negative, plug trach for 2 weeks. If all is well, pull trach.
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
How do you counsel patients/families whose goals of care are clearly aligned with a comfort-focused, end-of-life approach, but who are hesitant to formally enroll in hospice?
Hospice sounds like a 4-letter word to a lot of families! I find it important to distinguish the philosophy of comfort care vs. the benefit package associated with enrolling in hospice. Some people are able to be provided end-of-life comfort care without electing the hospice benefit, and that is fin...
Is there a maximum duration for raloxifene use?
There is relatively scant data on long-term raloxifene use in patients with osteoporosis, but generally, there are no recommendations for a drug holiday. The primary endpoint in the pivotal registration trial, MORE, was incidence of vertebral fracture, and the difference between the raloxifene and p...
How do you approach the significance of +RNP III antibody in a patient with positive ANA but no other signs or symptoms of systemic sclerosis?
RNA polymerase III is a specific autoantibody for a subset of systemic sclerosis associated with severe diffuse cutaneous scleroderma, renal crisis, GAVE, and a strong association with malignancy. If this antibody is identified in the absence of Raynaud's or other symptoms of scleroderma, its signif...
How do you approach the treatment of Crohn's colitis in the setting of immunosuppression for liver transplant?
Good question, as additional immune suppression can increase the risk of infection. The anti-rejection drug mycophenolate can cause diarrhea, which could mimic a Crohn’s flare. I individualize Crohn’s therapy in a liver transplant patient. What type of Crohn’s do they have? What meds were they on pr...
Do you suggest using a vascular probe to assess the superficial vasculature prior to performing a bedside procedure such as paracentesis, thoracentesis, lumbar puncture, etc.?
In our practice, we routinely use POCUS to assess the superficial vasculature before paracentesis and thoracentesis. Identifying vessels with POCUS is feasible, rapid, and may lead to a reduction in bleeding complications.1-6 For lumbar puncture, we use POCUS for site marking but not for vasculature...