Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When is it necessary to monitor the QTc interval in patients on hydroxychloroquine?
The answer to this question is not straightforward mainly because there are limited data in this area. Hydroxychloroquine and Chloroquine directly affect cardiac repolarization and are associated with QT prolongation. Given this, there is an argument for getting a baseline ECG for patients initiatin...
Are there any concerns about using nintedanib in a patient with progressive fibrosing ILD on background mycophenolate?
The SENSCIS trial randomized patients with SSc associated ILD to Nintedanib or placebo. I think about half of these patients were still taking MMF. There was no negative signal in the group on MMF and Nintedanib, they fared at least as well as those who got Nintedanib alone and both did better than ...
How would you manage an incidental catheter-related thrombosis in a functioning dialysis catheter?
If the patient is asymptomatic and the catheter is functioning well, I recommend starting anticoagulation.If the patient develops symptoms, he or she should still be anticoagulated but the catheter removed. Anticoagulation options in ESRD patients include Coumadin, Eliquis (my preference is a dose o...
What is the importance of finding a positive titer for FGFR3 and what treatment would be advised for these patients?
The significance of positive FGFR3 antibodies in patients with neuropathy, and the optimal treatment regimen for those patients remain to be determined. Based on the largest case series of FGFR3-IgG + patients to date, the antibodies seem to be associated predominantly, if not exclusively, with non-...
Are there scenarios where you send additional antibodies beyond anti-centromere, Scl-70, and RNA polymerase III in suspected scleroderma patients?
While these are the most common ANA subtypes in scleroderma, there are several other antibodies that are important. High titer ANA's with a speckled pattern may be U1 RNP and may be associated with overlap disease (MCTD). ANA's with a nucleolar pattern can be U3 RNP (fibrillarin), Th/To, or PM -Scl,...
For low rectal adenocarcinoma that extends to the anus through the internal sphincter muscle, would you recommend neoadjuvant therapy in a patient who will undergo APR?
Yes, since the margin is positive and local recurrence rates are high for low rectal cancer patients such as this, they should be treated with neoadjuvant chemoradiation including the inguinals with IMRT.
Would you start tocilizumab in a patient with temporal arteritis and cirrhosis?
This is a challenging question as data regarding this question is lacking and the decision should be individualized to the specific presentation and through shared decision making. In general, I would consider using TCZ in such clinical situations. While TCZ can cause hepatotoxicity, it's not typic...
What is your approach following R1 resection in a patient who has received total neoadjuvant therapy for rectal cancer?
This is a challenging scenario and there is not a one-size fits all solution. My decision making would involve thorough assessment of the patient's performance status, co-morbidities, pre-treatment extent of disease, tolerance of therapy, and review of what TNT regimen was employed: number of chemo ...
When do you trial pyridostigmine in a patient with suspected myasthenia gravis?
I usually try it very early on if I have a reasonable suspicion. Compared to the tensilon test and even the neostigmine test, a diagnostic trial of pyridostigmine is safer and more resource-efficient. Diagnostic trials of pyridostigmine are not particularly evidence-based, nor is treatment, but this...
Would you use inhaled steroids with or without oral steroids for the treatment of radiation pneumonitis?
I have not tried inhaled steroids instead of oral steroids for symptomatic radiation pneumonitis much in my practice. Many patients are already on inhaled steroids at baseline, and many who develop pneumonitis have severe symptoms. That being said, avoiding oral steroids could be particularly import...