Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there any utility to trending Histoplasma serology titers to guide duration of therapy or treatment response for pulmonary histoplasmosis with negative urine antigen?
Serology unfortunately is not useful to monitor response to therapy as the fall in titers is often very slow. In immunocompetent individuals, titers will often take a few years to show a significant drop in the antibody titer after successful treatment. The treatment duration should be guided by the...
Does a low serofast RPR titer (such as 1:1 or 1:2) in the setting of a remote history of appropriately treated latent syphilis in a patient with now uveitis of yet unknown etiology referred from ophthalmology for possible ocular syphilis make a diagnosis of ocular syphilis less likely?
I err on the side of offering empiric treatment. As syphilis rates have risen over the past 20 years, so has the incidence of syphilitic uveitis (Mir et al., PMID 37991790), and the question posed, therefore, represents a not uncommonly encountered conundrum for infectious disease consultants. Syphi...
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 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...