Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
How would you lead a goals of care discussion in terms of prognosis/survival likelihood for patients with inotropic dependent HFrEF with CRT-D on maximally tolerated GDMT?
I usually start by reviewing the prognosis with inotrope-dependent HF, quote data from DT VAD trials (REMATCH). I assess the eligibility for DT VAD and transplantation and review the shared decision-making pathways (IDECIDE LVAD) if the patient is eligible for DT VAD. If the patient is not a candida...
How soon following pacemaker implantation can patients safely undergo elective cardioversion?
That is a good question. From a technical standpoint, a cardioversion can be done at any time after a pacemaker implantation. In the past, we often did defibrillation threshold testing on patients on the EP lab table after implanting an ICD and sometimes they would require a shock externally. This w...
How does your hospital approach the use of insulin pumps for admitted patients?
Patients using insulin pumps are only on rapid-acting insulin, so that any interruption in the use of the pump requires them to switch to a combination of basal insulin and rapid-acting insulin. This is hard to do in a controlled outpatient setting (for example, technical failure of the pump), but v...
How do you approach the workup of subcentimeter contralateral nodules in cases of locally advanced NSCLC?
These are often challenging questions/issues in our multimodality discussions. A couple of "general" principles/considerations. I would try, if at all possible to prove the presence of metastatic disease, however in the case of sub cm contralateral nodules, this is, as the question alludes to, not a...
How would you manage an elderly patient with type 3 achalasia who previously underwent POEM and has recurrent dysphagia, high Eckardt score, and dilated esophagus concerning for blown-out myotomy on esophagram?
This is a complex clinical scenario which requires a multi-disciplinary approach at an expert center. One of the main goals is to decipher why the patient is still having symptoms. Is the patient is having symptoms due to persistent achalasia or due to the blown out myotomy. You can make this distin...
Is there any utility to trending Histoplasma serology titers to guide duration of therapy or treatment response for pulmonary histoplasmosis with negative urine antigen?
Serology unfortunately is not useful to monitor response to therapy as the fall in titers is often very slow. In immunocompetent individuals, titers will often take a few years to show a significant drop in the antibody titer after successful treatment. The treatment duration should be guided by the...
Does a low serofast RPR titer (such as 1:1 or 1:2) in the setting of a remote history of appropriately treated latent syphilis in a patient with now uveitis of yet unknown etiology referred from ophthalmology for possible ocular syphilis make a diagnosis of ocular syphilis less likely?
I err on the side of offering empiric treatment. As syphilis rates have risen over the past 20 years, so has the incidence of syphilitic uveitis (Mir et al., PMID 37991790), and the question posed, therefore, represents a not uncommonly encountered conundrum for infectious disease consultants. Syphi...
Would you recommend administering IV amino acids prior to cardiac surgery with cardiopulmonary bypass, given recent trial findings of improved AKI rates but no significant difference in kidney-replacement therapy with IV amino acids?
The trial by Landoni et al., PMID 38865168 in the August NEJM examined the effect of an amino acid infusion (2g/kg/day) in patient undergoing cardiac bypass surgery. They found a reduction in post-op AKI, but no change in the need for dialysis or mortality. Although this was a large (>3500 subjects)...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...