Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you diagnose and treat patients who develop uveitis while on bisphosphonate therapy for osteoporosis?
Ocular inflammation, usually anterior uveitis, can occur as a consequence of bisphosphonate therapy. Virtually always, the bisphosphonate is one that is given intravenously and the ocular inflammation begins a day or two after the treatment. Furthermore, the inflammation is generally self-limited; i...
What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?
If at all possible, I continue to use tocilizumab as a glucocorticoid sparing agent for patients with giant cell arteritis. Given the results of the GIACTA trial, the Villiger trial, and lots of observational data, it is clear that tocilizumab provides efficacy in terms of reducing risk of relapse a...
What are your recommendations regarding methotrexate usage in patients with persistent chest CT changes post COVID pneumonia?
With the raging pandemic and the steady stream of post-COVID inflammatory/fibrotic patients, we are bound to encounter patients with such abnormalities who are on potentially pneumotoxic drugs (or need initiation).With minimal concrete data, any recommendation is purely based on experience.Methotrex...
How would you manage a patient with acquired von Willebrand disease who requires DAPT for arterial disease?
Acquired vWF has many causes: lymphoproliferative disorders; MPN; autoimmune disorders; high flow disorders (Heyde syndrome) and drugs. Treating the underlying disorders would be the safest strategy because DAPT is going to cause bleeding per se in some patients and removing a second cause for bleed...
What particular pre-operative considerations should we consider for SLE patients undergoing elective surgery?
Our guidance in the perioperative management of systemic lupus erythematosus (SLE) patients is essential. A 2016 study showed they are at a much higher risk for falls, thrombosis, acute kidney injury, and infections compared to patients with osteoarthritis (Roberts). This increased risk is even pres...
How do you approach patients with underlying psychiatric disorders who refuse CML treatment due to not believing their diagnosis?
Importantly, having an underlying psychiatric disorder doesn't unto itself mean that the patient lacks the capacity to make their own medical decisions. Further information is necessary about the patient's understanding, their current status, etc., to make that determination. At many institutions, p...
Do you send an antiphospholipid antibody panel routinely for all patients with an unprovoked thrombus?
Yes. My own practice is to perform testing for antiphospholipid antibodies in all patients with unprovoked VTE and also in patients with arterial thrombosis. Testing should include assays for lupus anticoagulant, anti-cardiolipin antibodies (IgG and IgM), and anti-beta 2 glycoprotein I antibodies (I...
How would you manage VTE in a patient with bleeding disorder such as hemophilia?
Management of VTE in a patient with an inherited bleeding disorder depends on the specific disease, the severity of the bleeding disorder, and the past history of bleeding in that patient. In patients with serious past bleeding and low levels of factor, anticoagulants may be contraindicated and loca...
How do you approach the use of steroids for active muscle disease in patients with scleroderma-myositis overlap syndromes?
For patients with mild myopathy (mild weakness and CPK elevation), I tend to avoid steroids altogether if I can and just treat them with other therapy (like MMF or MTX). For patients with severe myopathy, particularly if they are very weak or have oropharyngeal weakness and at risk for aspiration, I...
At what platelet count would you feel comfortable dosing aspirin 81 mg for coronary artery disease in a patient with ITP?
In a patient with ITP, I would certainly feel comfortable dosing aspirin 81mg daily at a platelet of 50,000 or greater. As you know, the risk of bleeding in a patient with ITP is less than would be expected at a particular platelet count because the circulating platelets in ITP are young and large. ...