Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider tapering tocilizumab in patients with GCA in remission?
This is a timely question and recent data sheds some light on this important topic. The risk of GCA relapse is approximately 50% (Mainbourg et al., PMID 30951256) in all comers. The GIACTA trial (Stone et al., PMID 28745999) utilized a one-year course of TCZ. A recent publication of the extension ph...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.
What are some practical ways to incorporate cardiac POCUS in the primary care setting?
In the primary care setting, I find cardiac POCUS most helpful for triage of undifferentiated patients and for monitoring of changes such as volume status, keeping in mind: Cardiac POCUS has a wide spectrum of accessibility for novice users, from systolic function and chamber sizes (attainable) thro...
What is your strategy for counseling patients who don't qualify for colorectal cancer (CRC) screening under the current guidelines but are concerned with its increasing incidence at a younger age?
When counseling patients who are concerned about increasing rates of colorectal cancer among younger patients but do not qualify for screening based on current guidelines, I take the following approach: I try and elicit if there is any specific reason for their concern (signs, symptoms, family hist...
How do you evaluate a suspicious, but negative pleural effusion when working up NSCLC and SCLC?
Good question and this came up in my practice very recently (NSCLC). Historically, clinical trials have required 2 negative taps for entry. The patient I had in clinic appeared to have a node negative, LLL lesion with a ton of atelectasis and had a bloody tap that was negative for malignancy. It did...
Do you recommend routine use of protamine for hemostasis at the end of a transfemoral TAVI?
Always, in order to guarantee hemostasis of the femoral site and minimize femoral access complications. Dose is weight based, anegdotically lots of institutions give half the recommended dose as they still see some of the positive effects. Warning: ask about history of allergy/anaphylaxis. Protramin...
Do shorter door-to-balloon (D2B) times impact outcomes in STEMI, if it's already less than 90 minutes, and to what degree (i.e., 30 vs 60 minutes would have a more significant impact)?
No. Shorter door-to-balloon times have not been shown to improve survival or outcomes in STEMI. The reason is that the other variable is the time from the onset of chest pain to presentation to a medical facility. This time is beyond the control of the medical system. For example, a patient waits 4 ...
In addition to ampicillin, is there any benefit to the addition of either gentamicin or Bactrim when treating a patient with listeria meningitis?
There has been a lot of misinformation in the literature for decades about the treatment of Listeria bacteremia and meningitis/encephalitis. Some of this arose based on publications of in vitro studies that claimed that "PCN and ampicillin are bacteriostatic against Listeria." This was based on dete...
What procedures do you recommend for patients interested in xanthelasma removal?
I have had success treating xanthelasma with both hyfrecation (particularly for very small lesions) and fully ablative laser (both CO2 and Erb-YAG).
What is your approach to diagnosis and evaluation of nonbacterial thrombotic endocarditis (Libman-Sacks)?
Nonbacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks endocarditis, is a form of endocarditis characterized by the presence of sterile vegetations on cardiac valves. It is most commonly associated with systemic autoimmune conditions, notably systemic lupus erythematosus (SLE) and a...