Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients with active IBD and rectal cancer, do you take any precautions before starting TNT?
First, I would be sure that the patient really needs TNT. If a patient has active inflammatory bowel disease, they will not tolerate TNT very well. If a patient has inactive IBD, there is not likely to be much added morbidity. I would be very hesitant to use TNT if someone has really active IBD. The...
What could explain discordant iron studies?
This is an incredibly common question, largely generated by the zeal to use the serum ferritin and failure to appreciate the need for an overnight fast when ordering the TSAT (the ferritin does not require fasting). The most common culprit in this situation is iron containing vitamins. Prenatal vita...
How do you decide whether to use lung POCUS versus CT as the next step when a chest X-ray is equivocal for pneumonia?
Lung ultrasound is a quick, safe, and inexpensive test to perform. If the patient already has a chest X-ray and it is equivocal for pneumonia, I always perform a lung ultrasound. It is useful for evaluating an inflammatory vs. non-inflammatory interstitial process. It is better than an X-ray to dete...
In which cases would you consider early transition to DOAC (within 72 hours) for hospitalized patients with intermediate or high risk PE?
Two DOACs are FDA-approved for early use (within 72 hrs), rivaroxaban and apixaban. The PEITHO-2 dabigatran cohort study included no comparison group (its authors called it a "trial"?) and required "72 hrs" parenteral anticoagulant before dabigatran but the small print in its Lancet Haematology show...
Should bare metal stents be favored over drug eluting stents for pregnant patients presenting with acute coronary syndrome?
This is a great question. There is limited data that supports the safe use of DES in pregnant patients requiring revascularization (Regitz-Zagrosek et al., PMID 30165544). New-generation DES has a lower risk of stent thrombosis with shorter or even very short duration (28 days) of dual antiplatelet ...
When do you discontinue contact precautions in patients known to be colonized with ESBL-producing Enterobacterales?
There is no widely accepted guideline regarding the timing of discontinuation of isolation for ESBL-producing organisms. However, according to the article “Duration of Contact Precautions for Acute-Care Settings” published by ICHE in 2018, Maintaining contact precautions for ESBL-E and CRE for the d...
Are there factors that would prompt you to consider the use of methylene blue in refractory septic shock?
I usually don't consider using it unless all other options are exhausted. Although there is date that shows decrease in pressor needs, there is no data that shows any clinical improvements, and specifically no improvement in mortality. It is not part of my algorithm for refractory shock.
Do you use dual anti-platelet therapy inpatients with low NIHSS who have had bilateral brainstem strokes?
I usually look at the stroke mechanism in making my decisions about DAPT rather than just relying on the NIHSS alone. If the mechanism is ICAD, branch atherosclerotic disease, SVD (with infarct extension), embolism from the aortic arch plaque, subclavian artery heterogenous plaque, extra-cranial ver...
What leads you to suspect that a foot drop is secondary to a myopathy rather than a neuropathic process?
Factors suggesting that a foot drop is due to a myopathy include: Clinical factors (slow progression (myopathy but also seen in CMT) versus acute or sub-acute onset (usually neurogenic), absence of sensory findings, absence of pes cavus, signs of facial or shoulder girdle weakness (FSHD can cause f...
What is your approach to managing ILD associated with inflammatory bowel disease?
We must first convince ourselves that the "ILD" relates to the underlying IBD. Patients may be on an immunomodulating regimen that increases the risk of opportunistic infections. The regimen itself may cause diffuse pneumonitis. Environmental/occupational exposures may also play a role. Armed with c...