Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the diagnostic utility of ordering an "Early Sjogren's Syndrome Profile", which tests novel autoantibodies, to support a diagnosis of Sjogren's syndrome in patients who test negative for SSA/SSB?
Currently, there is not much diagnostic utility to ordering these novel autoantibodies in patients who are negative for SSA/SSB as it is unclear how to interpret the results. In a mouse model for Sjogren's (Shen et al., PMID 23123440), these novel autoantibodies appeared earlier in the course of dis...
Do you attempt more aggressive PEEP titration to improve the P/F ratio prior to proceeding with proning in patients with ARDS and P/F <150?
Aggressive PEEP titration is a loaded term. Do these patients need higher PEEPs? Yes, if they are recruitable. You need to understand the lung mechanics and the concept of stress and strain to make sure that you are optimizing the inflation pressure these lungs are exposed to. This can be achieved b...
Does aspirin dose (81 mg vs 325 mg) matter for secondary stroke prevention?
This topic has been debated extensively. There are two camps in this debate: Aspirin with a dose of 81 mg is adequate for platelet inhibition in the general population. Aspirin with a dose of 325 mg may be needed for individuals who weigh more (>70 kg) to achieve appropriate platelet inhibition. T...
Is there any indication for hydroxyurea in patients with sickle cell trait?
No. Of course, be sure it is the correct diagnosis and not HgA + HgS (beta+) which, as you know, shows HgA and HgS on electrophoresis and can/will be called trait if not looked at by someone experienced to note if A> S or if S > A. If MCV is low. If HgA2 is up. HgF up etc... If indirect Bili/LDH/AST...
Do you use terlipressin for patients with hepatorenal syndrome who also have elevated blood pressures?
There are those who would question HRS as a diagnosis if the patient had an elevated BP. Regardless, I believe its effect is related to BP so I would not use it in this situation.
How do you approach the decision to use terlipressin in a patient with hepatorenal syndrome type 1, AKI, and a history of heart failure given its potential cardiovascular effects?
I usually do a full workup to make sure the etiology of AKI is type 1 HRS. Would also make sure bleeding or infection not complicating the clinical scenario. This is not as simple as it seems, especially in the setting of primary heart failure as a complicating factor, and requires thorough thinking...
Have you seen drug induced SCLE from IL-17 inhibitors?
Fortunately, drug-induced subacute cutaneous lupus erythematosus (diSCLE) induced by IL-17 inhibitors is rare. I have never seen a case, but there are at least 3-4 cases in the medical literature (from brodalumab, ustekinumab, and secukinumab: Ang et al., PMID 33511692, Tierney et al., PMID 30891478...
What is your approach to achieving hypernatremia in a patient on CRRT for whom increasing the rate of a post-filter 3% sodium chloride infusion is insufficient?
Good question. First, we can always increase the rate of the 3% saline more. Eventually, the increased amount of salt will lead to an increase in serum sodium concentration. It has to be a gradual process though to make sure one does not overshoot. Second, if the patient does not require more dialys...
How do you manage arthritis resulting from deferiprone in transfusion dependent thalassemia?
The precise pathophysiology of deferiprone associated arthropathy is not well understood but some reports have suggested that there may be some deposition of iron in the synovial membranes, and some subchondral bone damage. Unfortunately, there is no specific treatment for this arthritis, other than...
Would you recommend a CT venogram or MR venogram in patients with concern for venous sinus thrombosis?
Either modality is suitable for assessing CVST. However, I typically prefer CTV. It's easier to obtain and has a quick scan time, which reduces the chances of motion artifacts. MRV provides better resolution, but it requires a screening form and has a longer scan time, which may lead to motion artif...