Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In patients taking biologics who are planning joint replacement and are known MRSA carriers do you perform decolonization prior to surgery?
Is there a role for phlebotomy in secondary polycythemia?
Prefatory to answering the question, I think it's important to specify the full nature of the problem because there is confusion in the hematology literature about the criterion used to define erythrocytosis as well as the phlebotomy target in secondary erythrocytosis. Currently, hematologists use t...
Do you offer iron supplementation to a patient with iron studies that are normal (including normal ferritin) except for low iron saturation?
The answer is absolutely and positively yes. A low percent saturation of transferrin has an extremely high concordance with absent marrow hemosiderin and frankly, in today’s parlance is the best indicator of “iron need”. While the ferritin is marvelous at confirming iron deficiency if low (with or w...
How do you approach management of a patient with Sjogren's disease and lung mass biopsy revealing amyloidosis?
A lung mass showing amyloid in SjD may reflect systemic amyloid or local/focal amyloid. Interdisciplinary assessment is recommended (Fraenkel et al., PMID 34101376). Organ systems involved will guide the expertise needed.Immunohistochemistry and molecular studies are needed to define if there is an ...
How would you approach the work up of a patient with nasal septal perforation, a negative infectious workup, and negative ANCA titers?
This clinical scenario can be difficult for the rheumatologist to evaluate, and close collaboration with colleagues in ENT would be essential. Causes of nasal septal perforation include trauma, infectious etiology, and autoimmune conditions such as granulomatosis with polyangiitis or microscopic pol...
Is whole body PET scan sufficient to rule out cardiac involvement in sarcoidosis?
Whole-body PET scans, particularly using 18F-fluorodeoxyglucose (FDG), play a significant role in evaluating sarcoidosis, including cardiac involvement. Recent studies have investigated the effectiveness of whole-body PET scans in diagnosing isolated cardiac sarcoidosis and assessing both cardiac an...
Do you routinely screen for sleep apnea in patients with acute ischemic stroke?
We at least ask the patient and family about sleep apnea symptoms. In patients who answer positively, or in those who deny symptoms but have obvious risk factors such as obesity, we do make the referral to our sleep clinic.
Do you recommend placement of a backup AV fistula in an advanced CKD patient who is planning to do peritoneal dialysis?
This is a controversial point for which I don't believe there to be great data. An old study in the British literature- I can't get my hands on it right now- purportedly demonstrated that only 7% of such fistulae were ever used/ useable. With improved fistula technique and survival this number is un...
What is your institution's active surveillance protocol?
The topic of active surveillance continues to evolve in light of the PIVOT trial and rapid adoption of mpMRI for initial staging. The 2014 NCCN guidelines summarize commonly used approaches, does not yet advocate for mpMRI, but declares an urgent need for more research. Meanwhile, the 2014 NICE Guid...
Should we be more concerned about cardiac toxicity following breast radiotherapy?
The way I interpret the data with all caveats that threshold dose and time period for any cardiac morbidity is significantly lower than what was expected. For that reason, all efforts should be made to avoid any direct photon beam wherever possible to go through any portion of heart by using any one...