Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there any difference between colchicine 0.5mg vs 0.6 mg for high risk coronary artery disease?
Based on my subjective practice, no significant difference (have used both formulations). Any others have any different/similar experiences?
When do you recommend plasmapheresis/plasma exchange for management of severe hypertriglyceridemia?
Generally, I recommend plasmapheresis for severe hypertriglyceridemia when patients are admitted with acute pancreatitis who either do not respond to NPO (and/or insulin if they have hyperglycemia) or if they are critically ill with for example necrotizing pancreatitis. Triglyceride concentrations d...
Would you add an SGLT2 inhibitor to augment diuresis during a hospitalization in a patient with nephrotic syndrome, an eGFR above 30 mL/min/1.73m2, and refractory hypervolemia on an intravenous loop diuretic?
Establish true loop diuretic refractoriness (minimum frequency: BID, the max dose depends on CrCl). Add sequential diuretics. Metolazone or other thiazide-like diuretics, with without amiloride or spironolactone. (Latter diuretics are preferred if the patient is hypokalemic). Add 25% albumin if e...
What is your approach for patients with recurrent nephrolithiasis who you have a strong suspicion for primary hyperoxaluria though genetic testing returns without any abnormalities?
As an adult nephrologist, most of my patients with oxalosis have enteric hyperoxaluria. I suggest you take a careful history, looking for inflammatory bowel disease, removal of small bowel or surgical rerouting of the intestines. If your patient is a child, I would explore the possibility of insuran...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
How do you manage incidentally identified pituitary lesions on brain imaging?
Pituitary lesions are among the most common incidentalomas seen on brain MRIs. Various studies cite numbers as high as 10- >30% for pituitary lesions found incidentally on brain imaging, with the higher incidence rates emerging in the era of high-resolution MRIs. In pediatric neurology/neuro-oncolog...
How do you interpret CSF pleocytosis in the context of significant leukocytosis on CBC?
There is no correction factor as there would be for CSF vs serum glucose, for example. A patient with leukocytosis in peripheral blood, for example, due to urosepsis would not always have elevated CSF WBC unless there were concomitant meningoencephalitis. I would consider 100 WBC abnormal for CSF re...
Is there any role for IVIG or steroids in viral myositis complicated by severe rhabdomyolysis, diffuse compartment syndrome, DIC, and AKI?
There is no evidence to support the use of immunosuppression in the case of viral myositis, besides supportive measures for rhabdomyolysis, and a review of the patient's medication list and habits to rule out other toxins that could contribute.
How would you manage a patient with highly active ankylosing spondylitis, iritis and Crohn’s, controlled with weekly adalimumab with co-morbid IgG4RD and intolerance of azathioprine due to elevated LFTs?
There is not a known association between IgG4-RD and IBD or spondyloarthritis. Given that these are rare diseases, it is important to ensure diagnostic accuracy, as the combination of these diseases would be unusual, though not impossible. There are two types of autoimmune pancreatitis: type 1 (IgG4...
How do you approach severe anemia and thrombocytopenia in an elderly patient whose bone marrow biopsy shows hypercellular marrow with mild dysplasia in erythroid and megakaryocytic lineage but normal cytogenetics and a negative NGS panel?
This is a really interesting case! Few things to consider: The presence of a small PNH clone suggests marrow injury however, the marrow is usually hypo rather than hypercellular in this scenario. It may be worthwhile to send HLA typing. The presence of HLA-B14:02, HLA-B40:02, and HLA-B07:02 alleles...