Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage a patient with severe RA or SLE that worsens after stopping immunosuppressants due to having chronic foot ulceration?
Fear the foot ulcer! These portals of entry for microorganisms can wreak havoc in immune-compromised patients. Rheumatologists must ensure that these lesions are being properly managed. Since healing can often be prolonged in some of our patients, the decision of whether and when to resume immune su...
What is your approach to treating crowned dens syndrome?
Crowned dens syndrome is said to account for as much as 2% of acute neck pain. The diagnosis is mostly clinical. The patient will present with acute neck pain, elevated acute phase reactants, calcific deposits overlying the dens on x-ray or CT scan, and the lack of an alternative diagnosis. In >40 y...
Is there a reason to repeat HMGCR antibody level for monitoring disease activity once documented positive in patients with IMNM?
HMGCR antibody persists even when the disease is quiescent, and levels of the antibody correlate with the log of the CPK levels. Therefore, it is not a very sensitive marker for disease activity, so it is not a useful marker to follow longitudinally. Instead, CPK is a cheaper and more sensitive mark...
Do you typically screen patients for antiphospholipid antibodies in autoimmune diseases besides lupus in the absence of a clotting event?
I would check antiphospholipid antibodies (APLAs) in a few situations in the absence of thrombotic events: 1. In someone with other APS manifestations: Obstetrical complications (especially) APL nephropathy noted on renal bx Unexplained adrenal hemorrhage/microthrombosis Non-infectious endocardial v...
What is your approach to counseling a patient with stable but severe multivessel coronary disease if the patient does not wish to undergo bypass surgery?
The question assumes that a stable patient with multivessel disease would do better with bypass surgery. If the ejection fraction is less than 35% then the long-term outcome from the STITCH trial showed a reduction in mortality. There is no comparable data for angioplasty. If the patient refuses sur...
What are your next steps when managing patients with suspected Gitelman syndrome for whom genetic testing reveals variants of uncertain significance or novel mutations not well characterized?
If the patient had a clinical syndrome that fit the Gitelman phenotype I would totally treating as such.
How do you approach the treatment of drug-induced thrombotic microangiopathy?
Typically, transplant-related TMA is due to sirolimus, tacrolimus, cyclosporine, or some combination of those drugs. The first step is to reduce the dose. Often keeping the drug at the lower end of the therapeutic level, the TMA will resolve or ameliorate. If, for instance, sirol and tac are used to...
Which factors would prompt empirical lead extraction in bacteremic patients without TEE evidence of lead vegetation?
My point of view is to have a very low threshold to extract a device where infection is likely. The presence or absence of lead vegetation may be a bit misleading as lead thrombi are not uncommon. I think the presence of a thrombus may make us feel more resolute in the removal plan though this may b...
How do you approach treating idiopathic aortitis?
Before classifying a patient as ‘idiopathic’ or ‘clinically isolated aortitis’ (CIA), one must carefully consider that the aortitis may be a manifestation of a systemic condition, particularly giant cell arteritis or Takayasu arteritis. Other systemic diseases associated with aortitis include IgG4-...
What duration of dual antiplatelet therapy do you use for secondary prevention of ischemic stroke due to intracranial atherosclerotic disease?
It is a fair question that we don't have a solid evidence-based answer for. I agree that the SAMMPRIS trial was driven by events within the first 30 days, although this was primarily driven by procedure-related events in the stented group. We do know that intracranial athero (ICAS) risk of stroke re...