Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to radiographically suspicious lung nodules for which initial biopsy was negative for malignancy?
It depends on how suspicious the nodule is for malignancy clinically and on the biopsy. The following criteria play into my decision-making: If the kinetics (steady growth over multiple scans) and morphology (solid and spiculated) on CT as well as hypermetabolism on PET-CT are highly suggestive of ...
Do you choose an antibiotic with CSF penetration, such as nafcillin over cefazolin, in the setting of MSSA endocarditis with septic emboli to the brain (assuming no concomitant meningitis or brain abscess)?
The prevailing theory that cefazolin has poor CNS penetration is really based on 3-4 studies performed in the 1980s (Nolan & Ulmer, PMID 7365282) where they were extrapolating data from studies looking at cephalothin concentration in CSF. Another study looking specifically at cefazolin concentration...
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
Do you use direct oral anticoagulants to treat port-a-cath related VTE in patients with an active malignancy?
The initial trials that established DOACs as effective and safe in most patients with cancer-associated thrombosis (Agnelli et al., PMID 32223112, Planquette et al., PMID 34627853) only included patients with lower-extremity DVT or PE but clearly showed equivalence to low-molecular weight heparin (w...
In patients with possible Bartonella henselae infection and elevated IgG titer, what is the best way to confirm the diagnosis: tissue biopsy with Warthin-Starry staining, tissue sent for Bartonella henselae PCR, or tissue sent for culture?
First of all, it is important to only test people with a compatible clinical syndrome. If the syndrome is not that of babesia, then any positive tests are likely to be false positives. This is a basic testing principle. A very low pretest probability is likely to lead to false positive testing. The ...
Do you utilize the bronchiectasis severity index (BSI) in your approach to managing non-CF bronchiectasis?
I calculate it for academic reasons in my bronchiectasis clinic. It perhaps affects the frequency of visits in the clinic. Otherwise, not much practical application. I respond to daily cough and secretion management with stepping up airway clearance, and to frequency bronchiectasis exacerbations wit...
When do you consider the use of clonidine in gabaergic withdrawal and how do you approach the risk of masking the autonomic signs of withdrawal when it is used?
There is limited and indirect evidence for the use of clonidine in "benzodiazepine-sparing" protocols for gabaergic withdrawal treatment. Generally, an anticonvulsant is used along with clonidine in this context. This "new" data recapitulates old, mainly European, studies combining beta-blockers wit...
How do you differentiate between hyperactive delirium and excited catatonia?
This is a highly complex distinction to make for several reasons, not the least of which is that the two conditions can coexist in the same patient at the same time. This has been demonstrated in some recent studies of mainly intensive care delirious patients, though the reported very high incidence...
In light of recent trials evaluating NPO before cath (CHOW NOW, SCOFF, etc.) are centers still restricting oral intake pre-procedure?
Despite compelling growing evidence supporting that NPO is safe for diagnostic procedures (coronary angiogram, RHC), most institutions are still reluctant to change, likely related to: Medical inertia Nursing staff hesitation Upper management Medical liability M&M related concerns Lack of guideline...
How do you rule out empyema in a small pleural effusion that is not amenable to thoracentesis?
Ultrasonographic findings indicate empyema, such as complex septated or non-septated/echogenic effusions Wang et al., PMID 35984158. However, if the effusion is too small, it may be difficult to characterize, limiting the diagnosis. Moreover, when the effusion is so small, the likelihood of empyema ...