Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you treat RA in patients with pulmonary mycobacterium avium complex (MAC) infections?
This is a very complex situation and requires teamwork between rheumatology and infectious disease with close patient follow-up and treatment. In general, avoiding TNF inhibitors in these patients is preferred, in particular the monoclonals, with close monitoring. Methotrexate is an option, and in t...
Is antiplatelet or anticoagulant therapy preferred for the secondary prophylaxis of cryptogenic stroke in a patient with underlying malignancy?
Will look at the stroke radiographically. If appears embolic and the patient is low risk for bleeding, with respect to their cancer regimen, co-morbidities, and labs, I will discuss off-label anticoagulation with eliquis. If there are additional, chronic embolic appearing strokes - that will also sw...
What is your inflammatory arthritis differential when a patient presents with unilateral TMJ synovitis?
The differential of TMJ disease depends on the age group. In the younger population, JIA must be very high on the differential. In adults, the differential includes RA, dermatomyositis, systemic sclerosis, systemic lupus erythematosis, and spondyloarthropathies (Ankylosing spondylitis and psoriatic ...
What is your approach to screening for cardiac involvement in patients with myositis and how does the finding of cardiac involvement change your management?
Cardiac involvement in IIM can often be overlooked but reportedly occurs at a high rate (~up to 75%) in a subclinical fashion. This can run the gamut of myocarditis, arrhythmias, conduction defects, cardiomyopathy, heart failure, and atherosclerotic disease. Screening for this often starts with an E...
How does your treatment algorithm differ for drug-induced ANCA vasculitis compared to non drug-induced ANCA vasculitis in cases with severe/organ-threatening manifestations?
When end-organ manifestations are present, my initial treatment approach is similar for drug-induced and non-drug induced AAV and typically consists of glucocorticoids and rituximab, including pulse glucocorticoids with severe end-organ involvement. Common drug culprits such as PTU, hydralazine, min...
How would you attempt to determine the etiology of intracranial hemorrhage in a patient with newly diagnosed lupus and an active viral infection?
My typical evaluation of a case like this is as follows: 1. Evaluate their lupus disease activity: CBC, CMP, ESR, CRP, C3, C4, dsDNA, urinalysis, urine protein/creatinine ratio (latter two are more for eval of renal disease) 2. Evaluate the cause of ICH: a. MR to further evaluate for other non-ICH r...
How do you counsel Takayasu patients on their prognosis?
Unfortunately, patients with Takayasu arteritis have a higher mortality rate compared to the general population. Most studies suggest a 3-fold higher standardized mortality rate in patients with TAK compared to age-matched healthy controls. Survival rates following TAK diagnosis vary notably between...
Are stress-dose steroids indicated in patients with adrenal insufficiency receiving radiation therapy?
I am not aware of any direct analysis or study that has addressed this question specifically for patients undergoing radiation treatment, but I can comment on the present indications for perioperative stress-dose glucocorticoids in adrenally insufficient patients, from which certain inferences to Ra...
In gout, do MSU crystals form only in tissue, or are there circulating microcrystals of MSU within blood vessels?
The solubility of MSU is dependent upon solute, temperature, and pH. Even with a rapid rise in total body uric acid as seen with tumor lysis syndrome, where uric acid levels can exceed 15 mg/dL, I have never heard of an MSU crystal identified in a serum sample. As I explain to students and patients,...
Is it ever appropriate to use hydroxychloroquine temporarily in higher doses (more than 5mg/kg) to control lupus activity such as skin manifestations?
The risk of retinal toxicity with long-term use of doses higher than 5mg/kg was shown by Melles and Marmor; PMID 25275721. There are reports of developing retinal toxicity even with short-term use of HCQ mostly coming from oncology literature (e.g. Navajas et al., PMID 26651304).There is some publis...