Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage patients on biologics peri-operatively?
There was an article in the NEJM Journal Watch in regards to stopping biologics (DMARDs and TNFs) for rheum disease before surgery, and there was no statistically significant benefit in regards to surgical recovery but, as expected, flares of the Rheum disease. In regards to the newer targeted injec...
What is the antifungal prophylaxis regimen that you use in patients on peritoneal dialysis who are receiving antibiotics?
Data indicates that either nystatin (500,000 U qid) or fluconazole (200 mg q48 hours) is effective in minimizing the risk of fungal peritonitis in PD patients being treated with antibiotics. See the most recent ISPD guidelines (Kam-Tao Li et al., PMID 35264029) for details. As there is less risk of ...
When would you consider neuro-stimulants in post-stroke patients?
To my knowledge, there are no large, randomized trials supporting the use of neurostimulants in stroke rehabilitation. When patients are too sleepy to participate in therapy, I have been known to use very low-dose methylphenidate or modafinil. Levodopa has also been tried with mixed results.
Is there a subset of ANCA vasculitis patients for which you would try plasma exchange?
Circling back to this now that we have more data. I agree with Dr. @Dr. First Last's main conclusion that GN or the presence of concomitant anti-GBM antibodies are the primary scenarios in which there may be a role for plasma exchange patients with ANCA-associated vasculitis.Following the PEXIVAS tr...
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
Are there instances when you prefer serum creatinine over cystatin C when estimating GFR in a patient with CKD?
Overall serum cystatin C correlates better with measured GFR than does serum creatinine. The main block to more widespread use of cystatin C is its cost. I personally have not had an experience where the serum creatinine has been a better measure of GFR as opposed to serum cystatin C but there is da...
Do you recommend giving IV albumin with furosemide to augment diuresis in a patient with hypoalbuminemia and volume overload?
I'm a fan of IV albumin in patients with edema and hypoalbuminemia <3g/dL. It stabilizes intravascular volume and may blunt the rise in serum creatinine that can occur with diuresis. It may lead to a decrease in serum creatinine in some patients, especially those with liver disease and impending hep...
What is your approach to progressive calvarial hyperostosis found in an elderly adult not caused by Pagets, acromegaly or hypercalcemia?
Does your patient have meningioma? Is the osteosclerosis generalized or localized? Localized osteosclerosis can arise from tumors (either benign or malignant) that secrete osteogenic proteins. I have had such a patient, with the unresectable meningioma secreting endothelin. Endothelin is also secret...
Would you start any treatment for radiation pneumonitis if there is a large area of consolidation in the irradiated lung field but the patient is asymptomatic?
If the timeline matches then for radio graphic only pneumonitis, I would favor observation with a repeat scan in a few months.
Is there a role for nintedanib in the management of patients with radiation-induced pulmonary fibrosis?
There is no phase III evidence I am aware of on the benefits of nintedanib in the prevention of radiation-induced pulmonary fibrosis so it is not a drug I use. There are a few case reports and some pre-clinical studies suggesting an effect. There is a small (34 patients) randomized phase II study th...