Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?
This is a difficult question with no definitive research-proven answer. Clearly, most of our drugs do enhance the chance of melanoma and nonmelanoma skin cancer. If one does a literature search the only one of our drugs that has not been reported to increase the chance for relapse of melanoma is Tac...
How do you approach treatment of vasospasm after AVM rupture?
In my practice, ruptured AVMs are managed in a way somewhat similar to aneurysmal SAH rupture. Initial DSA evaluates the AVM’s angioarchitecture and identifies high-risk features, such as intra-nidal or branch feeder aneurysms. These high-risk features are addressed during the acute phase of managem...
In what clinical context would you consider offering first time catheter ablation for symptomatic atrial fibrillation in patients with advanced heart failure, as opposed to a trial of antiarrhythmics and/or cardioversion?
I would favor first-time catheter ablation in patients with advanced heart failure as a way to improve LVEF%, symptoms, reduce risk for recurrent hospitalizations, and decrease mortality. Many patients with advanced heart failure have an enlarged LAVI, so DCCV will only be a temporary solution and a...
Is there any clinical benefit in referring patients with SLE or Sjogren's with cognitive impairment for neuropsychological testing?
I have been grappling with this issue more often in fibromyalgia and chronic fatigue syndrome and more recently in patients with Post-acute COVID Syndrome. In FM and CFS I have not found neuropsychological testing helpful to distinguish true cognitive impairment from the confounding effects of sever...
How do you approach the use of commercial testing such as AVISE CTD in clinical practice?
Short story to start off with: A little over 20 years ago, I was a young rheumatologist sitting in a meeting room full of more experienced rheumatologists from the Washington DC area. Some of them were very well known in the field. The person in charge asked, "anti-CCP antibodies are now available t...
How do you approach tapering immunosuppression in a patient with a history of Susac Syndrome who has stabilized on MMF and IVIG?
Susac's is a rare disease characterized by an occlusive retinal vasculopathy, eighth nerve disease including hearing loss and balance issues, and CNS disease with a predilection for involvement of the corpus callosum. I am not aware of any randomized controlled data to guide treatment for Susac's, b...
When do you consider ketamine to treat nonconvulsive status epilepticus?
Ketamine is a fine agent for the management of status epilepticus (SE) and some centers use it first line instead of propofol or midazolam. Mechanistically, it makes more sense as it controls the seizures through NMDA blockade, bypassing GABA receptors, which are downregulated in the setting of SE. ...
When would you consider using acetazolamide to augment diuresis in patients with ADHF?
The ADVOR trial suggested that the addition of acetazolamide to a loop diuretic "upfront" in congested patients with heart failure achieves greater decongestion at 72 hours and discharge. While most would not use such a combination in "all" patients, this strategy is optimal in those demonstrating s...
How would you manage recurrent migratory lower extremity thrombophlebitis that occurs despite being on therapeutic apixaban?
The differential diagnosis of Trousseau syndrome (migratory superficial thrombophlebitis) is relatively broad and includes both inflammatory states and undetected proximal DVTs. So I think the short answer about venogram is "maybe," based on how clear is the view by ultrasound. This isn't a typical ...
What is your preferred first-line agent for VTE prophylaxis in hospitalized medical patients with adequate renal function?
Lovenox. It can also be dose adjusted for poor renal clearance if needed; otherwise, Heparin.