Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you think about deferring VTE prophylaxis versus implementing non-pharmacologic methods when chemical prophylaxis is contraindicated?
No good reason not to use mechanical/non-pharmacological methods for VTE prophylaxis. Modality may not be ideal, but it is a generally accepted alternative when you cannot use chemical/pharmacological agents.
Can giant cell arteritis present with a partial cranial neuropathy?
Giant cell arteritis (although giant cells on temporal artery biopsy are not a sine qua non) most typically presents to the neuro-ophthalmologist with ischemic optic neuropathy (usually anterior and sometimes posterior).Ophthalmoplegia is uncommon in GCA but has been attributed to oculomotor and abd...
Is there any role for prophylactic bronchial artery embolization in immunocompromised patients with invasive pulmonary aspergillosis?
Bronchial artery embolization is NOT without complications. Although the bleeding risk is very high in invasive pulmonary aspergillosis, empirical embolization is not well supported either by data or clinical practice. It probably should be a case-by-case decision.
What is your approach to managing patients who initially present with symptomatic intracranial large vessel occlusion but subsequently experience resolution of symptoms or become non-disabling before any intervention?
If a large vessel occlusion (LVO), such as ICA-terminus, M1, or Basilar, is present, I would treat it even if there has been a significant improvement in symptoms. As mentioned in the prior post, an occlusion in one of these areas will likely exhaust collateral reserves and become symptomatic again....
When would you consider aspirin for long term management of unprovoked VTE after initial therapeutic anticoagulation?
The WARFASA trial randomly assigned patients with first unprovoked VTE who had completed 6-18 months of anticoagulation to 2 additional years of aspirin versus placebo. While the study demonstrated a 40% reduction in recurrent thrombotic events, the rates of VTE in those receiving aspirin were still...
Do you recommend any CRRT prescription changes for optimal clearance for patients with AKI who are on a reduced blood flow rate due to concurrent regional citrate anticoagulation?
In distinction to conventional HD, solute clearance in CRRT is limited by dialysate/replacement solution flow, not blood flow. So, no, I do not make changes in the CRRT just because of a decrease in blood flow rate.
Is there a risk of hepatitis C activation with rituximab in a patient who has a history of HCV treated with antivirals and who is in sustained viral response?
In general, the risk of HCV flare with immunosuppression in general including rituximab must be viewed as minimal for those who have achieved a sustained virologic response (Undetectable HCV RNA ≥12 weeks after treatment completion) and does not influence my therapeutic decision-making if the patien...
When would you consider a kidney biopsy in a patient with longstanding diabetes and hypertension (baseline creatinine 4-5, 4+ proteinuria) who was recently found to have dsDNA positivity?
Only if something changed clinically, urine protein abrupt increase, hematuria microscopic, increase in trajectory of creatinine, or symptoms suggestive of SLE. I feel bad when I biopsy a diabetic only to find diabetic nephropathy, but if you never find diabetic nephropathy, you aren't doing enough...
Should intervention be considered for an intermediate flow-limiting coronary lesion that does not correlate with perfusion defects on stress testing in a patient with atypical anginal symptoms?
This is a kind of question that gets into the realm of the "art of medicine". There are multiple questions within this single question. I will try to answer each of them. What is an angina and what is atypical angina: I have come across a wide variety of angina syndromes throughout my clinical expe...
How would you approach pursuing a kidney biopsy in a patient with suspected lupus nephritis who is on warfarin for antiphospholipid antibody syndrome?
This is a decision to be made carefully involving multiple specialists. Personally have had a bad experience with resuming anticoagulation after kidney biopsy. I have seen patients bleed even one week after doing the kidney biopsy when resuming anticoagulation. Can switch to a heparin drip before th...