Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When would you add a third antibacterial agent in addition to macrolide and ethambutol for treatment of a patient with HIV and disseminated MAC?
Add 3rd agent for patients failing or not on ART regimen when diagnosed with disseminated MAC Optimize failing ART. For treatment-naïve or not on ART, start ART ASAP after MAC therapy All our samples are sent to National Jewish Health in Denver, CO, right away for drug resistance testing If no clin...
Is it safe to combine mycophenolate and adalimumab for management of pulmonary sarcoidosis in a patient that could not tolerate methotrexate?
Combination therapy is often required in patients with sarcoidosis. Combination of adalimumab with other immunosuppressants, such as methotrexate, leflunomide, azathioprine, or mycophenolate, can be used, with close monitoring of labs (CBC, CMP) and for infections.
How is transferrin saturation a reliable indicator for any parameter if serum iron is not reliable?
The question is a very good question. The Fe/TIBC must be drawn on an overnight fast including any vitamin pills containing iron. Otherwise, the serum iron is speciously elevated which in turn speciously elevates the TSAT. If those conditions are met, the TSAT is as good as the transferrin receptor ...
Should oral combined contraceptives be held prior to overnight dexamethasone suppression test to rule out Cushings?
Yes, they should be stopped for one month due to an increase in cortisol levels secondary to oral estrogen-increasing CBG. However, many women will still suppress while on OCP. Therefore, an alternative approach is to do the test while on OCP and to repeat it off OCP if the test is abnormal.
What is your approach to withdrawal of ventilatory support at the end of life?
This is a great question with a complex answer. Both options are reasonable and in my practice, I gear compassionate extubation practices towards the patient and family wishes. In conjunction with our Palliative Care team, we have an algorithm for providing medications to ensure the patient's will n...
Do you administer prophylactic antibiotics to prevent VAP following intubation in patients with acute brain injury?
I currently do not, though this trial is interesting and the results are compelling. I think the risk of one dose of CTX is low. No clear evidence of resistance. I think moving forward, I would have a low threshold for administering one dose of ceftriaxone following intubation in my TBI patients. Ho...
How would you treat a patient with combined pre- and post-capillary pulmonary hypertension after successfully optimizing post-capillary pressures through a valvular intervention?
No good data here. First, if I'm contemplating treating this group with pulmonary vasodilators at all, I would like to see repeat RHC demonstrating precapillary pulmonary hypertension with a low wedge. Fixing the valvular disease may help with left-sided function, but many of these patients have dev...
What work-up do you recommend in patients with early-onset dementia?
After a thorough history (especially drugs, alcohol and Family Hx) - would do: imaging study, TSH, B12 level and consider genetic labs and CSF for early onset dementia.
Does biotin interfere with the measurement of other metabolites of the Vitamin D pathway outside of the 25-hydroxy Vitamin D assay?
Biotin interferes with chemiluminescent assays. Assays using LCMS to measure 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D, and 24,25-dihydroxyvitamin D are not affected.
Do you prefer assessing cystatin C or creatinine when monitoring a patient’s eGFR who is receiving chemotherapy for malignancy?
If the patient is on a drug known to interfere with creatinine handling in the renal tubules (e.g. abemaciclib), then I will intermittently check the cystatin C to differentiate true AKI from pseudo-hypercreatinemia since these drugs can also cause true AKI.