Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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.
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...
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...