Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
When would you consider offering PVC ablation for otherwise healthy patients with preserved LV systolic function?
I would generally not offer an ablation for PVC burden alone but may consider further workup/counseling or even ablation if other factors are present. I would obtain a more detailed history to determine if the patient has symptoms/limitations that they did not initially express, which would lead me ...
How do you approach determining appropriateness for extubation in a patient with acute respiratory failure in the setting of known chronic neuromuscular disease?
This can be a very challenging situation in the ICU. I first discuss the options with the patient (if possible) and caregivers before considering extubation. I consider baseline/pre-illness data if available such as prior FVC or NIF/MIP, need for NIV, etc. Also, it is important to consider why they ...
Is there a role for SGLT-2 inhibitors in the treatment of chronic hypomagnesemia?
A meta-analysis of 18 randomized controlled trials showed that the use of SGLT2 inhibitors can result in a significant increase in the serum magnesium level. These trials, however, were not specifically designed to assess the effect of SGLT2 inhibitors on the serum magnesium level. Studies have show...
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
What are the indications for anticoagulation in splenic infarctions?
A great reminder that splenic infarct relates to ARTERIAL thromboembolism and not to VENOUS VTE. Too often, I see massive, blind thrombophilia work-up for (incidentally) detected splenic infarcts.
How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?
APL testing as well as evaluation for SLE and Sjogrens with complement, urine, antibody testing, not just an ANA.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
For patients who have previously undergone MAZE ligation presenting with paroxysmal atrial fibrillation, how would you counsel them on the risk of stroke long-term when deciding whether or not to start or continue anticoagulation?
The decision to start or continue anticoagulation in patients with atrial fibrillation can be challenging, even after LAA closure. Specifically related to surgical closure of the LAA (excluding percutaneous LAAO, such as Watchman or Amulet), anticoagulation is still recommended indefinitely if suppo...
Are there instances when you use erythropoietin stimulating agents in patients with acute kidney injury requiring dialysis?
I cannot think of a reason to. ESA resistance is common in sick patients and I think you are wasting the drug. Please see reference: Aoun et al., PMID 35279078'Erythropoietin treatment had no impact on transfusions, renal recovery or mortality in acute kidney injury patients with anemia."