Sarah C. Hull, MD, MBE (Master of Bioethics)

All posts by Sarah C. Hull, MD, MBE (Master of Bioethics)

January 25th, 2013

Appropriate Use or Defensive Medicine?

Is the practice of defensive medicine overriding the implementation of appropriate use to the detriment of economics, patient care, and medical education?

December 1st, 2011

Heart Over Head or Head Over Heart?


A 52-year-old man presented with 3 episodes of transient dysarthria and right-sided facial numbness within a 2-week period. A carotid ultrasound revealed >70% stenosis of the left-internal carotid artery and 50%–69% stenosis of the right coronary artery. At age 40, the man had been diagnosed with non-Hodgkin lymphoma, which was treated with cranial radiation and anthracyclines, […]

April 21st, 2011

Will a STICH in Time Save Nine?


A 57-year-old man with a history of hypertension, hyperlipidemia, and smoking presented with increasing dyspnea on exertion, mild chest discomfort, and lower-extremity edema. Physical exam results were consistent with decompensated heart failure. Echocardiographic findings: left-ventricular ejection fraction (LVEF), 20% LV end-diastolic dimension, 6.3 cm global hypokinesis (with regional variation affecting the septum, inferior wall, and apex most […]

March 2nd, 2011

Questioning the DOSE

Although widely used for decades, the best way to use loop diuretics in patients with acute decompensated heart failure (ADHF) has never been well studied. The Diuretic Optimization Strategies Evaluation (DOSE) study, published in the New England Journal of Medicine, randomized 308 ADHF patients to a bolus every 12 hours or a continuous infusion of furosemide at […]

October 22nd, 2010

Warfarin or Dabigatran? The Thick and Thin of Deciding on an Anticoagulant

These four patients are receiving chronic anticoagulation therapy. Read the descriptions of their cases and decide which, if any, of them you would switch to dabigatran.   Case 1  A 69-year-old man with a history of hypertension and colon cancer was found to be in atrial fibrillation during a preoperative assessment for colon resection. Metoprolol was […]

September 6th, 2010

What’s at the Heart of This Patient’s Problem?


The patient is a 53-year-old lawyer with no cardiac risk factors other than a 70 pack-year history of smoking. He has a known history of diverticulitis with prior gastrointestinal bleeding and presented with lightheadedness and bright red blood per rectum. Initial evaluation revealed a drop in his hematocrit from 43% to 39%. He underwent a […]

May 27th, 2010

The Tests Say Intervene, but the Patient Feels Fine


A 58-year-old asymptomatic man with hypertension and hyperlipidemia was noted to have an abnormal electrocardiogram during his routine annual physical examination. His primary care physician ordered a treadmill stress test. The patient exercised for 6 minutes and 39 seconds of a standard Bruce protocol, achieving 8.1 METs. He stopped because of dyspnea. His heart rate increased […]

March 31st, 2010

Her Cancer Treatment Is Working, but Her Heart Is Failing


The patient is a 57-year-old woman with a history of Hodgkin disease of the anterior mediastinum. Upon being diagnosed at age 26, she was treated with a staging laparotomy, splenectomy, and 36 Gy of radiation to the mantle and para-aortic areas. She did well until September 2009, when she developed increasing dyspnea on exertion, weight […]

February 17th, 2010

Which Strategy for Severe Calcific Aortic Stenosis?


The patient is a 72-year-old man with a history of ischemic cardiomyopathy (LV ejection fraction, 30%–35%) and NYHA class II/III heart-failure symptoms at baseline. Over the previous month, he had experienced recurrent episodes of volume overload and sustained ventricular tachycardia (VT) requiring intravenous diuretics and up-titration of his amiodarone therapy. He then presented in VT […]

December 18th, 2009

Deciding When to Bridge


A 61-year-old man presented with 6 hours of chest pain and ECG changes consistent with an acute anterior-wall myocardial infarction. His cardiac troponin I was 59 ng/mL. Urgent angiography revealed an occluded LAD and 70% proximal OM1, 70% proximal OM2, and 90% proximal RCA stenoses. He was taken to the catheterization laboratory, where an attempt to open the […]