Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
At what point in GCA management do you typically introduce tocilizumab?
I typically introduce tocilizumab as first line therapy in combination with prednisone in patients who do not have a contraindication. The GIACTA trial demonstrated the superiority of TCZ+prednisone x 6 mos over prednisone alone x 6 or 12 months with numerically fewer serious adverse events. Given t...
Do patients with an elevated IGF-1 level and features of acromegaly need to have confirmatory growth hormone suppression testing with OGTT?
OGTT is not always needed. In the presence of clinical features of acromegaly, a frankly elevated IGF-1, and a pituitary adenoma visible by MRI glucose suppression test is not necessary.
Do you rule out active urinary tract infections prior to performing a kidney biopsy?
The 2 infectious reasons to avoid a renal biopsy are- active kidney infection and active skin infection at the site of the biopsy (Luciano & Moeckel, PMID 30661724).Perinephric hematoma is common after a kidney biopsy and there is a report in the literature where this has gotten infected in the pres...
When would you consider utilizing bone scintigraphy in the assessment of inflammatory arthritis?
When it's a case of negative RA disease or when considering a neoplastic, gammopathy with myeloma...
Do you typically adjust or hold immunosuppression in a well-controlled RA patient who is being treated for Mycobacterium avium-intracellulare (MAI)?
It depends on the RA activity and shared decision-making with the patient. A lot of these patients are at risk of MAI infection due to their underlying immunosuppression and on higher levels of immunosuppression because they have more severe rheumatoid disease process. Very often it is difficult for...
Are CGRP antagonists effective at aborting intractable headaches in hospitalized patients when traditional “migraine cocktails” have failed?
The time has come for us to limit ourselves in our treatment of migraine patients to migraine-specific medications. These are the triptans and gepants for abortive treatment and the CGRP antibodies and gepants for preventive treatment. The "migraine cocktails" that we employ in emergency room and ho...
Would you consider reducing the dialysate sodium concentration to 135 meq/L as a strategy to decrease interdialytic weight gain in a hypervolemic ESKD patient?
Yes. It is worth a try. I don't expect miracles though. It may make a minor difference. The best option remains longer and more frequent dialysis if possible and agreeable with the patient which is often not the case.
How do you manage hyperalgesia in patients with sickle cell disease?
In addition to the obvious, such as PCA narcotics, Lyrica/Neurontin, and Toradol, I have success with IV Tylenol, Zyprexa, po L-Arginine (Morris et al., PMID 23645695) as well as Dexmedetomidine (Precedex), steroids (NEJM: Griffin et al., PMID 8107739) and acupuncture [Johnson et al., Alternative an...
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...