Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you recommend switching to DAPT for patients on anticoagulation who develop symptoms of a TIA secondary to ICAD?
It is important to remember that there is more to stroke secondary prevention than antithrombotics. Our use of DAPT in ICAD comes from the SAMMPRIS trial, in which patients in the control group did better than expected compared to historical controls with ICAD in the WASID trial. Recall however, tha...
What is your approach to urate lowering therapy in patient with gout who is on azathioprine (for example, for transplant), where allopurinol and febuxostat are both contraindicated?
This is unfortunately not an uncommon scenario. As mentioned in the question, xanthine oxidase inhibitors such as allopurinol and febuxostat are contraindicated in patients on azathioprine or 6-MP and using them almost always leads to cytopenias due to azathioprine/6-MP toxicity (even in low doses)....
How do you approach the management of patients with suspected membranous lupus nephritis who are found to have positive PLA2R antibodies?
In a patient with known SLE with proteinuria > 500 mg/g and (+) PLA2R antibodies in the serum, a kidney biopsy would be warranted. PLA2R staining should be performed on the kidney biopsy. PLA2R staining must co-localize on the subepithelial aspect in a granular fashion similar to IgG in PLA2R posit...
How would you approach the treatment for patients with renal-limited ANCA vasculitis who have persistent proteinuria, hematuria, and ANCA titers and have completed a steroid taper and received three doses of rituximab?
Renal limited ANCA is usually MPO associated. Isolated PR-3 involvement of the kidneys are rare. Further information is needed in making a decision for this case. We need to know when the patient was diagnosed with ANCA vasculitis. What was the Serum creatinine at presentation? When was the kidney b...
Do you recommend initiating immunosuppression and plasmapheresis in patients with dialysis dependent AKI in the setting of anti-GBM disease who do not have pulmonary involvement?
Anti-GBM disease is a rare disorder (incidence perhaps 1:1,000,000 adults/year) that is characterized as a small vessel vasculitis mediated by anti-GBM antibodies directed against the alpha-3-chain of collagen IV in basement membranes. Perhaps half of patients have disease that involves both the kid...
How do you evaluate livedo reticularis (not livideo racemosa)?
Livedo reticularis appears as an interrupted vascular network on the lower limbs. One does not need to warm up the affected area in order to make this diagnosis. The response to heat usually occurs in cutis marmorata that is found in children. Livedo reticularis when it is acquired in teenage and la...
Do you prefer scopolamine patches, glycopyrrolate, or other treatment regimens to manage oropharyngeal secretions at the end of life?
Terminal respiratory secretions, the “death rattle,” may occur during the dying process. Noisy breathing may upset family members, but can also be a normal part of dying. It is important to stop non-essential IV fluids that may contribute to volume overload and pulmonary edema. The head of the bed m...
How do you treat patients with Linear IgA that are deficient in G6PD?
Quite a unique clinical situation! One in which the diagnosis is rather rare, but with an added wrinkle where the most classic textbook therapy, dapsone, cannot be used.A few case reports have shown that omalizumab and dupilumab have been reported to effectively treat LABD: Almuhanna et al., PMID 37...
Do you treat prosthetic joint infections after a two-stage revision arthroplasty with oral antibiotics for the full duration of therapy, assuming a susceptible oral option is available?
This is a hard one-I definitely think the data is there for PO, but until the IDSA recommendations change and the culture of practice changes it is hard to make the switch to doing a full regimen PO! I also think the accountability of IV antibiotics is useful -with the visiting nurse, weekly labs, i...
What are some immunosuppression regimens to consider in a patient with refractory cardiac sarcoidosis?
Unfortunately, there is no high quality data at this point to directly answer this question but here are some options. For patients who have only been treated with oral steroids, I would first consider the addition of weekly methotrexate at a dose of between 10 - 20 mg WEEKLY with supplemental folic...