Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you avoid intra-articular and bursa/tendon sheath corticosteroid injections in patients with a history of avascular necrosis?
I would give intra-articular or bursa injections of steroids/glucocorticoids in patients with either active ON or a history of GC induced ON. I do not believe the local injection will increase the risk of progression or incident ON, as long as it is not given more often than every 3-4 months.
Should the age at which patients transition from pediatric to adult care differ depending on the disease diagnosis?
First, a distinction needs to be made between transition (which is a long-term, ongoing process) and transfer of care (which is the act of going to one provider to another). Transition introduction should start early, with recommendations that age 12 is a good beginning to introduce the concepts of ...
How would you manage a patient with morbid obesity who presents with new symptomatic pulmonary embolism a few days after he was started on DOAC for DVT?
There are guidelines from the American Society of Hematology and The International Society of Hemostasis and Thrombosis as well as expert opinions recommending either apixaban or rivaroxaban for venous thromboembolism or pulmonary embolism in patients with BMI >40. In addition, this includes use as ...
Do you use amyloid lowering therapy in patients on chronic anticoagulation?
I wouldn’t feel comfortable doing this because of the elevated risk of ARIA-H. The Alzheimer’s Association Therapeutics Work Group advised that patients receiving anticoagulants should not be offered lecanemab (Cummings et al., PMID 37357276).
For patient with polycystic kidney disease and proteinuria who are on maximum dose of ACEi/ARB, what are other anti-proteinuric medications that should be considered?
This is a great question because it highlights that patients with ADPKD should have proteinuria worked up as with any other patient with CKD - sometimes even by biopsy if needed (if tissue can be obtained safely, usually requiring urology and possibly using laparoscopic approach if ultrasound is not...
Do you recommend plasmapheresis for treatment of patients with osmotic demyelination?
No. There are insufficient data to routinely recommend plasmapheresis for the treatment of ODS at this time. Current evidence is based predominantly on case series. In the absence of a control group, it is difficult to assess the effectiveness of plasmapheresis in the treatment of ODS.
What is your approach to establishing a dry weight in a pregnant patient with ESKD on hemodialysis given the expectation of weight increase and pregnancy-related edema?
I think there is a lot of nuance managing weight in pregnant patients with ESRD. Pregnant patients have better fetal and maternal outcomes when clearance is increased. Outcomes are best with >36 hours of dialysis per week. Adjustment of dry weight should include assessment of volume status, blood pr...
How do you approach immunosuppression in patients with a positive Interferon Gamma Release Assay and prior intravesicular BCG treatment for bladder cancer?
Bacillus Calmette–Guérin (BCG) is the most widely used vaccine worldwide and has been used to prevent tuberculosis for a century. BCG also stimulates an anti-tumor immune response, which urologists have harnessed for the treatment of non-muscle-invasive bladder cancer. As rheumatologists, we occasio...
Is it sufficient to maintain patients with atrial fibrillation and established PAD on a DOAC or VKA alone, or is there an additional benefit to adding an antiplatelet agent for CVD benefit?
If they have medically managed PAD with no recent intervention/revascularization, anticoagulation alone should be sufficient especially if their bleeding risk is not low. In general, most patients on anticoagulation for AF do not need to also be on anti-platelet agents for secondary prevention. Exc...
How do you decide between administering or deferring upstream P2Y12 inhibitor treatment until patient is in the lab for NSTEMI or STEMI cases with unknown coronary anatomy?
Unless you are using clopidogrel there’s no need to consider upstream use in STEMI. In NSTEMI, you can use heparin/lovenox or a P2Y12 no need for both. If you don’t know the anatomy you’re gambling to give upstream P2Y12. In ACS administration of a P2Y12 inhibitor before assessment of coronary anato...