Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is it clinically necessary to provide supplemental oxygen to patients with mild, asymptomatic hypoxemia only during activity while they are recovering from an acute respiratory illness?
My practice is to withhold supplemental oxygen in patients with mild, asymptomatic hypoxemia during exertion when the underlying condition is expected to improve. I am not aware of strong evidence supporting the benefit in these cases, and I believe the potential harms generally outweigh any theoret...
In patients with post-MI LV thrombus which resolves after 3-6 months of anticoagulation, would you consider surveillance imaging for thrombus recurrence if there is persistent apical akinesis?
I think the key word here is akinesis (or dyskinesis); effectively, an immobile segment of myocardium gravitationally farthest south of the ‘northward’ flow of blood across the aortic valve. This effectively allows for stasis in an injured and immobile region... two of the three components of Vircho...
What factors influence your choice between low-dose DOAC therapy and dual antiplatelet therapy for the first 3 months after percutaneous left atrial appendage occlusion?
Using the ADALA study and previous observational studies, the use of apixaban 2.5 mg BID appears to be at least as safe if not safer than the use of DAPT. As a result, in patients who are unable to tolerate full-dose anticoagulation, low-dose DOAC is my first line. However, if patients have cerebra...
For how long do you treat an early spinal hardware infection secondary to MSSA after operative washout and retention of hardware?
This infection is a key research interest of mine and one I'm deeply passionate about. I typically treat with a 12-week induction regimen, preferably using antibiofilm-active agents—an approach adapted from the DATIPO trial for prosthetic joint infections (PJI). I generally do not recommend routine ...
Do all patients referred for acute symptoms of TIA or minor stroke require additional imaging with CT/MR angiography, in addition to admission/observation?
Regardless of whether symptoms are minor, improve, or resolve, it is important to obtain vessel imaging to evaluate the underlying head and neck vasculature, as this may guide additional treatments (e.g., carotid revascularization, ICAD management, dissection management, carotid-web management, etc....
Does 4G/5G polymorphism in the plasminogen activator inhibitor (PAI-1) gene increase the risk of thrombosis?
Venous thromboembolism (VTE) is a classical example of a multifactorial disorder where genetic and environmental factors interact to result in VTE. Of the genetic disorders, in isolation, many are weak risk factors but when combined with other genetic or one or more environmental risk factors increa...
For how long would you hold anticoagulation before percutaneous left atrial appendage closure with Watchman or Amulet devices?
Elective left atrial appendage occlusion with both Watchman and Amulet systems most often utilizes continuous uninterrupted oral anticoagulant administration (including the day of procedure) along with intra-procedural heparin to ACT 250-400 during implant. Procedural heparin is reversed immediately...
Do you ever consider close clinical monitoring over antifibrotic therapy in patients ascribed an MDD diagnosis of IPF who have normal lung function and are asymptomatic?
Idiopathic pulmonary fibrosis is by definition a progressive disease with high mortality, thus, clinical practice guidelines would recommend treatment at diagnosis. Based on US and UK epidemiologic studies, IPF has an average life expectancy of 3-4 years without antifibrotic treatment. Furthermore, ...
What patient characteristics prompt you to prescribe vericiguat for patients with heart failure with reduced ejection fraction who are already on standard therapy?
When considering the addition of vericiguat for patients with HFrEF who are already on standard therapy, several patient characteristics guide my decision-making process: Recent Decompensation: I particularly consider vericiguat for patients who have experienced a recent episode of heart failure de...
Do you always stop dexamethasone at discharge for patients admitted with COVID requiring respiratory support (as done in the RECOVERY trial), or are there situations in which you will prescribe it to complete a 10-day course?
Great question. Generally, I don't continue dexamethasone if they are no longer wheezing or generally feeling back to their baseline. Sometimes, I will extend the course if the patient has been in the hospital several times for COPD, just to see if I can keep them out of the hospital longer. But the...