Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you recommend administering IV amino acids prior to cardiac surgery with cardiopulmonary bypass, given recent trial findings of improved AKI rates but no significant difference in kidney-replacement therapy with IV amino acids?
The trial by Landoni et al., PMID 38865168 in the August NEJM examined the effect of an amino acid infusion (2g/kg/day) in patient undergoing cardiac bypass surgery. They found a reduction in post-op AKI, but no change in the need for dialysis or mortality. Although this was a large (>3500 subjects)...
What would be your approach to a patient with new diagnosis of seropositive rheumatoid arthritis manifesting as a constrictive pericarditis with no joint pain complaints?
This is an interesting clinical scenario. It highlights some of the current issues we face as rheumatologists, namely an atypical presentation of one of our more common diseases. This patient is labeled as having seropositive rheumatoid arthritis yet lacks arthritis features. I suspect the diagnosis...
Would you avoid combining JAK inhibitors with IVIG given the risk of thromboembolism?
The evidence for this is not very clear and limited. I think a honest discussion about the risk of JAKs and IVIG with the patient will be the most important; but as long as there is no clotting history or high risk of DVTs/PEs, and this is documented, and if a patient needs both medications to attai...
What factors influence your decision between guidewire exchange versus removal and replacement through a new tunnel tract for patients with tunneled hemodialysis catheter mechanical failure?
Mechanical failure of a tunneled dialysis catheter (TDC) could be from catheter cuff extrusion form the exit site, catheter thrombosis or a fibrin sheath. In all three scenarios I prefer guidewire exchange rather than removal and replacement of the TDC. Removal and replacement are much more invasive...
What is your approach to evaluating a patient with a suspected myocardial contusion?
Echocardiogram and troponin levels...
What is your approach to management of tremors in a kidney transplant recipient who is taking a CNI for immunosuppression?
This can be a really vesing problem for patients. My approach is somewhat dependent upon the severity of the tremors. I will sometimes try some low dose propranolol, 10 mg po BID-TID, or more often I will try converting from a the shorting acting forms of tacrolimus (Q12 hour formulations) to the lo...
What is your approach to inpatient immunosuppression for a kidney transplant patient on home tacrolimus, prednisone, and mycophenolic acid who cannot tolerate anything by mouth?
When someone is NPO or cannot tolerate tacrolimus by mouth we give it sublingually. The sublingual dose is twice as potent as po so if someone is on 2 mg twice daily PO we would give 1 mg SL bid and monitor levels. Mycophenolate mofetil is available IV and is a 1:1 dose. Someone on 500 mg po bid MMF...
How long would you treat an upper urinary tract infection in a patient with acute obstructive pyelonephritis due to a kidney stone status-post urinary stenting without yet removal of the stone?
After treatment of an ascending urinary tract infection for 7 days, the infection will be treated. However, if the stone is large enough it may be colonized and cause recurrent infection. I would make my best efforts to get the stone removed as soon as possible and I would likely give the patient a ...
Do you check for EGFR and other mutations in patients with squamous cell lung cancer, including in adjuvant setting before considering immunotherapy?
Yes, I do. Our Cancer Institute performs NGS reflex testing for all patients with newly-diagnosed lung cancer, regardless of stage or histology. Although EGFR or other mutations are less common in squamous cell lung cancer, they do exist, and this also allows for testing for other mutations (MET exo...
For patients who do not have access to biologic therapies, what are some csDMARD combination pearls or tips that you have that have particular efficacy in different rheumatologic diseases?
I normally use MTX in RA. I initially aim for 15mg of MTX per week, then split the dose and maximize to 20-25mg/week. In some patients, I use SQ MTX if they have GI problems or are very obese. The addition of HCQ with MTX is better than MTX alone in some patients. I have rarely used SSZ+MTX+HCQ but ...