Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients with concurrent, CAD and atrial fibrillation, more than 1 year post-PCI, the most recent AHA/ACC guidelines state that “oral anticoagulation monotherapy is recommended over the continuation of oral anticoagulant therapy and a single antiplatelet therapy.” If this individual undergoes surgery, the anticoagulant will be held. Would you then bridge with aspirin?
This depends on the surgery and for how long anti-coagulation needs to be held. For example, if the patient is undergoing CABG, then the answer is yes, and aspirin seems reasonable. But for some surgeries, all 3 drugs would need to be held (ophtho or some neurosurgical/spinal procedures for example)...
How would you manage a patient with diffuse Systemic Sclerosis who develops severe rapidly progressive calcinosis?
Unfortunately, calcinosis cutis is a very challenging and frustrating manifestation of Systemic sclerosis to tackle. When extensive, response to trial of interventions is further unlikely or poor. The primary goal of treatment is to minimize symptoms and alleviate functional limitations rather than ...
How would you approach a stage II colon cancer with negative ctDNA but markedly elevated CEA level post-colectomy?
Thanks for the question. Highly complicated case. Few things matter here. First, what platform is used for ctDNA testing (whether tumor informed or not), and second whether this is T4 or T3 disease. It would be unusual to have high CEA but negative ctDNA in a true minimal residual disease (MRD). For...
Is there any role for iron chelation in a patient with iatrogenic transfusion-induced iron overload such as in patients with end-stage kidney or liver disease?
There is a point with transfusion that iron overload starts to cause significant organ damage. With the advent of deferasirox (Jadenu), oral iron chelation can maintain equilibrium with ongoing transfusion. I would not start till ferritin is 1500 or higher to avoid risk of chelation of other heavy m...
Do you consider Anti-carbamylated protein antibodies (anti-CarP) as having any significance in evaluation of patients if RF and ACPA negative and clinically no active synovitis yet widespread arthralgias and generalized osteoarthritis?
Anti-CarP has been touted as another biomarker for early RA with rates of positivity in ACPA and/or RF-negative patients ranging from 4.5 % in a recent study by Ricchiuti et al., PMID 35885566 to 23.6% in the French ESPOIR cohort. Ricchiuti described anti-CarP tracked the most closely with 14-3-3 et...
Do you routinely use hypertonic saline for pulmonary toileting in patients with non-CF bronchiectasis?
We routinely use hypertonic saline (3% or 7%) inhaled twice daily with oscillatory PEP therapy in non-CF bronchiectasis. The Aerobika device is helpful as the saline can be directly administered through the device with an Aeroeclipse nebulizer, which many patients find more beneficial. I have found ...
What is your threshold for pursuing bone marrow biopsy in a lupus patient with cytopenias?
I rarely do bone marrow biopsies in patients with SLE as cytopenias are caused primarily by the disease itself and/or medications, primarily Azathioprine and Cyclophosphamide. SLE patients routinely have profound lymphopenia, neutropenia, and thrombocytopenia. I consider bone marrow biopsy in patien...
Would you give pentoxiphylline and vitamin E during HBO for vaginal necrosis?
My usual approach to treating radiation injuries in the pelvis would be to start with Vitamin E (Vit E) and pentoxifylline (PTX) for less severe radiation-related injuries, but in cases with ulceration and/or necrosis or bleeding requiring transfusion to proceed directly to hyperbaric oxygen (HBO). ...
Do you perform spontaneous breathing trials on higher levels of PEEP with extubation to positive pressure ventilation in patients intubated for obesity hypoventilation syndrome?
Yes. But like anything patient selection is key and the rationale for the use of higher levels of PEEP (e.g. improve oxygenation vs prevention of atelectasis for simplicity sake) factors into the decision (as do co-morbidities -heart failure, pulm HTN, etc). The literature nor weaning guideline do ...
How do you manage patients with status dystonicus?
Many times, severe, seemingly uncontrollable generalized dystonia can occur in patients with or without a prior history of dystonia. In cases of severe encephalopathy, often treating the encephalopathy is the best overall approach, with medications specifically targeting the movement disorder used s...