Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the stepwise investigation of patients suspected of inflammatory myopathy?
I have published an algorithmic approach to suspected inflammatory myopathy in Continuum Lifelong Learning in Neurology from AAN (Manousakis, PMID 36537973). Unfortunately, the article is not free, and I can't attach the algorithm in this response, because it's a PPT file. Happy to provide it upon r...
Would you recommend PFO closure in patients >60 years old with presumed paradoxical embolism as their mechanism of stroke?
Technically, based on the available clinical trial evidence, PFO closure is not indicated for patients over age 60 or for patients whose stroke was > 6 months ago. However, we frequently need to extrapolate from clinical trial populations to manage the patients we see in practice. Also, presumably, ...
How do you approach management of bone marrow involvement in sarcoidosis?
Monoclonal TNF inhibition would be an option as it is less likely to cause cytopenias and has shown some effectiveness in extrapulmonary Sarcoid. I have 2 patients who have anecdotally who have done well in the past.
Is it safe to continue azathioprine in a patient with severe bilateral panuveitis (thought to be related to sarcoidosis) and benign ethnic neutropenia, given worsening neutropenia since starting the medication, or should an alternative immunosuppressive agent be considered?
In this case, I would consider stopping azathioprine and switching to an alternative medication, such as an anti-TNF agent. Although not a large drop in the PMN, azathioprine is known to cause leukopenia, and in a patient with known neutropenia, extra precaution should be taken. In the case of uveit...
How do you discuss harms of MGUS screening with other medical providers?
I understand the intent of the question, but - as always - real life is more complicated. I agree that the evidence for screening completely healthy patients for MGUS does not currently exist. But, for patients with unexplained pertinent lab/imaging findings or symptoms, it's not unreasonable. In th...
What agent and for how long would you treat a patient with asymptomatic azole-resistant C auris candiduria who is planning to undergo a urological procedure?
I would be cautious here. If there are reasonable MICs to fluconazole (SDD but achievable), this would be preferred. Intravesical amphotericin is a good option. But, if this were impossible to achieve, I would be reluctant to use IV amphotericin in any formulation, since there's a risk of harm, and ...
How long would you continue chronic transfusion therapy for adult sickle cell patients who have had a stroke?
Management of stroke in adults is not informed by the data that is available for children. Assuming that this was not a hemorrhagic stroke and that there was no moya-moya, I would continue transfusions indefinitely. To slow iron accumulation, I would use an exchange transfusion aiming for an HbS lev...
What are the next steps in the management of a patient admitted with an IPF exacerbation resistant to steroid therapy?
IPF exacerbation is associated with a poor prognosis, with an in-hospital mortality rate of up to 50% in one study (Song et al., PMID 20595144). As discussed earlier by Dr. @Dr. First Last, there are currently no established or evidence-based pharmacotherapies for managing IPF exacerbation. Aggressi...
What criteria do you use to determine when to start a steroid-sparing agent for hypersensitivity pneumonitis?
This is a very challenging question, acknowledging the difficulty in confidently establishing the diagnosis of HP, limited evidence in general to guide the treatment of HP, and recent small observational studies that conflict prior small observational studies. To attempt to answer, breaking down int...
Are there instances where you may transiently transition a perioperative ESKD on PD inpatient from peritoneal dialysis to hemodialysis if they are likely to receive a large volume of fluid?
Most peritoneal dialysis patients should be able to continue with PD while in the hospital. For patients with acute volume overload, hypertonic dextrose solutions can be used. However, there may be special circumstances where patients on peritoneal dialysis will need a temporary transition to hemodi...