Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
Do you recommend automatically starting CRRT anticoagulation when initiating CRRT if there are no medical contraindications to anticoagulation?
Great question. My practice is that we don't. However, I wonder if we should. In any case, it is not unreasonable not to give it at the beginning and start it if the patient clots daily or more often. I think bleeding episodes tend to be very dramatic at times and result in clouding our judgement a ...
Are there instances when you recommend initiation of dialysis in patients with advanced chronic kidney disease who are scheduled for a major surgery but do not currently have any indications for renal replacement therapy?
There is this very annoying (annoying because I don't want to believe it) literature regarding CV surgery patients with CKD stages 4-5, but not on RRT, doing better post-op if dialyzed pre-op. It rarely rears its ugly head. Maybe there is something there despite my denial, or better yet my skepticis...
Do you avoid sodium zirconium cyclosilicate use in your patients with ESKD and hyperkalemia who also have peripheral edema?
I don't. The extra salt intake is a problem but so is the hyperkalemia. In general, I am conservative in giving potassium binders in hemodialysis patients because of the risk of polypharmacy.
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...
What work up do you recommend for persistent subclinical hyperthyroidism with decreased RAI uptake and negative thyroid antibody tests?
If the RAIU is very low, then this may be subacute thyroiditis. Lymphocytic or silent has no biochemical confirmatory tests. If there is pain, this suggest pseudogranulomatis subacute thyroiditis associated with a high URI and a recent viral infection. The other choice is they have some nodular thyr...
What are the implications of immunosuppressive therapy in a chronic asymptomatic T cell lymphopenic adult undergoing lung transplant evaluation?
The details of T cell lymphopenia are not mentioned for this patient. Idiopathic CD4 T cell lymphopenia is a recognized clinical syndrome which has been studied extensively (Lisco et al., PMID 37133586). The need for lung transplant is not detailed and raises the question if the two are related. It ...
Do you recommend holding ACE inhibitors, ARBs, and SGLT2 inhibitors for patients with chronic kidney disease and malignancy who are about to start high-dose intravenous methotrexate?
This is obviously an opinion-based question since there are no clinical data on this topic. If a patient has risk factors for AKI (underlying CKD, advanced age, low body mass) then it may be reasonable to hold RAAS blockers prior to treatment and resume following the completion of that cycle of high...
Would you consider using IVIG for POTS in the absence of any clear autoimmune condition or abnormal antibodies?
I completely agree with the answer above. It would be a pretty rare consideration, overall. Recent placebo-controlled and blinded studies examining the efficacy of IVIG for idiopathic or antibody-associated (FGFR, TSHDS) small fiber neuropathy found no benefit of the treatment in terms of small fibe...