Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What would be your differential for a wrist monoarthritis in an elderly female with erosions on MRI after less than 3 months of symptoms?
I would put CPPD arthritis high on the differential, as the wrist is a common site for CPPD arthropathy in the elderly. In the right context, septic arthritis is a possibility, particularly if the patient is immunosuppressed. Indolent infections such as fungal or mycobacterial are possibilities. Les...
Is it safe to treat checkpoint inhibitor-induced arthritis with methotrexate or biologics?
How the safety of methotrexate or biologics compares to long term steroid use to treated checkpoint-inhibitor inflammatory arthritis has not been determined. With that said, steroids can have deleterious effects on the tumor response in addition to all the other known side effects. Therefore, for pa...
What is your approach to bladder cancer surveillance in patients who have received cyclophosphamide?
Risk of bladder cancer following cyclophosphamide treatment can be associated with oral therapy and likely also related to cumulative dose (1). Risk of bladder cancer with intermittent IV cyclophosphamide has been reported in some observational studies, but has not been consistently reproduced (2). ...
How do you manage VTE in the setting of persistent severe thrombocytopenia?
The thrombosis versus bleeding risk ratio should be weighed. The risk of VTE recurrence or propagation is highest in the first 30 days and we know that thrombocytopenia does not attenuate this risk. Providers should favor anticoagulation. In the case of cancer-associated thrombosis and chemotherapy-...
How do you screen dermatomyositis patients for malignancy if they have a high risk antibody profile (NXP-2/TIF1gamma positive) and their initial screen is negative?
If an initial screen is negative, including age-appropriate malignancy screening, the need for additional testing in an NXP2 or TIF1 gamma patient would be driven by the clinical presentation and risk factors. An older patient with severe disease (including dysphagia, ulcerations, vasculitis), refr...
How would you approach moderate neutropenia (ANC < 1000) in a solid organ transplant recipient?
There are limited data addressing the safety and efficacy of G-CSF in the solid-organ post-transplantation setting. Most case series report no increase in graft rejection with G-CSF treatment, although this question is not rigorously answered. Most cases of neutropenia in the post solid-organ transp...
How often do you utilize soluble transferrin receptor or hepcidin testing in the diagnosis of ambiguous iron deficiency, such as with concomitant anemia of chronic disease?
Almost never. While the soluble transferrin receptor and serum hepcidin levels may provide useful information, their lack of ready availability and costs makes them inconvenient and inefficient as a standard. There is no evidence extant that either offers an advantage to the TSAT. All of this is a m...
How do you assess transaminitis in a patient with sarcoidosis with known liver involvement being treated with methotrexate?
This can be fairly tough, as you cannot assess for hepatoxicity from methotrexate in a patient who already has a transaminitis. Hepatic sarcoidosis occurs in 11-80% cases and is often asymptomatic. Some patients may have a transaminitis, elevated alk phos, or liver lesions noted on imaging. Serious ...
For which subset(s) of APS patients do you recommend an INR of 3 or higher?
According to the EULAR 2019 recommendations for managing APL (Tektonidou et al., PMID 31092409) and according to the 2011 APL Task Force recommendations: For secondary venous thrombosis prophylaxis, it is recommended to keep INR between 2-3. Patients who fail warfarin therapy at INR 2-3 may benefit ...
Do you avoid any specific biologic therapies in HIV positive patients?
At present, the most safety data on the use of biologics in HIV is TNF inhibitors. CD4 count should be > 200 and VL undetectable. Etanercept is most preferable, give lower incidence of serious infections as well as its efficacy as monotherapy (without methotrexate). Wangsiricharoen et al., PMID 2733...