Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to PEEP titration in the management of a morbidly obese patient with ARDS?
Unfortunately, there is no definitive evidence on how to best adjust positive end-expiratory pressure (PEEP) in morbidly obese patients with acute respiratory distress syndrome (ARDS) as patients with a body mass index (BMI) of greater than 35 kg/m2 were excluded from most of the large clinical tria...
Do you treat patients with culture positive mycobacterium abscessus if they are asymptomatic and do not have progression on imaging?
If by "symptomatic," the assumption is that patients have a productive cough, malaise, fatigue, and weight loss, they should be treated per protocol. We usually proceed with "shared decision making" discussing the nuances of untreated versus treated scenarios.
Do you routinely perform echocardiography in patients with Staphylococcus aureus bacteremia deemed low risk for metastatic infection, or do you selectively omit it based on specific clinical criteria?
A limitation of the applicability of this study is that no isolates of MRSA were detected. Thus, there would be no strains, such as USA300-like strains, with both virulence and resistance mechanisms. In this situation, the goal is to avoid morbidity and mortality from a uniformly deadly disease: S. ...
How do you interpret a high positive RNP in the setting of a negative ANA and negative sm/RNP?
This is a challenging scenario that we often see in clinical practice with our current multiplex assays. A great reference is the following ACR abstract: Clinical Significance of RNP Antibodies in Diagnosis of Systemic Autoimmune Rheumatic Disease When Detected By Multiplex Immunoassay. As demonstra...
When is a paraneoplastic panel indicated when working up patients with neuromuscular conditions?
How would you interpret a positive dsDNA in a patient with a negative ANA performed via indirect immunofluorescence?
Another important consideration is the methodology by which the anti-dsDNA antibody was assessed. Most commercial labs use EIA, which is sensitive but not as specific as Farr or Crithidia assays. Many positive EIA results are negative when checked by these more specific methodologies.
How do you approach a negative ANA and positive dsDNA in patients with arthralgia, hair loss, or other UCTD features?
This could easily be a person with early (evolving) ANA-negative SLE (depending on the dsDNA titer) or early UCTD. If the dsDNA titer is low my concerns are somewhat diminished. I certainly would not assign a diagnosis of SLE given the information provided, with special reference to the person's anx...
In patients who are on 3 of the 4 pillars of HF therapy for HFrEF, would you add the 4th pillar if they are no longer in symptomatic HF and LVEF normalizes?
This is a great question, and a data-free zone. The way I see it, the LV recovered with 3 pillars, and assuming the EF is normal and patient asymptomatic, I'm not sure what benefit is derived from the fourth pillar. I would not add it as there is no data that in patients with HFimpEF already on 3 pi...
Regarding CVST, what protocol of heparin dosing do you regularly use and does it change depending on clot burden/ICH status?
There is very limited randomized evidence for the use of anticoagulation in any form for CVST. We often rely on extrapolations from data on the acute management of DVT in the leg and pulmonary embolus. We are mainly limited to cohort studies and small RCTs. Recent trials in this area include the TO-...
Is there a role of maximizing GDMT medications for patients with durable VADs?
Yes. There is a role both to (1) reduce morbidity and mortality in patients with heart failure supported with durable LVADs and (2) the potential to promote myocardial recovery concomitantly with mechanical unloading provided by the LVAD. There is no published, prospective, RCT outcomes data yet to ...