Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you manage HIT in a patient with high bleeding risk?
If bleeding risk associated with the administration of an alternative anticoagulant is unacceptably risky, I usually recommend the administration of IVIG. Theodore E. Warkentin, PMID 31274032
Do you routinely obtain a chest x-ray prior to initiating anti-TNF or other biologic therapy?
I don't routinely order a chest x-ray in patients with negative quantiferon (or other latent TB testing such as the T-spot) before starting biologics. The chest x-ray is much less specific for latent TB, particularly in the United States where TB is not endemic. Patients may have granulomas or other...
Are you comfortable using DOACs in obese patients with VTE?
Although there are no direct randomized trials in this population of patients, emerging data from systematic reviews suggest that DOACs are non-inferior to warfarin in patients >120 kg. (Elshafei et al., PMID 32556939).
What is your preferred approach for patients with anti-phospholipid syndrome with recurrent thrombosis on coumadin and LMWH?
This is a difficult condition to manage and personalized approach/risk stratification is key. There are several potential considerations:Warfarin therapy could be intensified, anti-platelet agents could be considered (although not in combination with LMWH).For patients with an underlying autoimmune ...
Do you routinely check for copper deficiency as part of workup for bicytopenia with leukopenia/anemia or pancytopenia?
I do not usually check for this but not unreasonable if there is a clinical reason to check.
In patients with high-risk polycythemia vera with a history of thrombosis, should aspirin be used in addition to indefinite anticoagulation and cytoreduction for prevention of recurrent thrombosis?
I do not continue aspirin in patients who require anticoagulation out of concern for an increased risk of bleeding. In an analysis of the REVEAL database, patients receiving anticoagulation in combination with aspirin were over 4-fold as likely to have a hemorrhage (HR [95% CI] = 4.22 [2.57, 6.94]; ...
What is your typical workup for a patient with a spontaneous renal infarct?
Broadly speaking, in the setting of a renal infarct, consider a thromboembolic event (venous thrombosis with paradoxical embolism or an arterial source) or a local vascular event such as dissection. The latter can be easily missed because the appropriate imaging is generally not performed. Once a va...
What workup do you recommend for patients with stabbing headaches?
Stabbing headaches, also called icepick headaches or jabs & jolts, are severe pains in the head, often occurring spontaneously but sometimes caused by coughing or sneezing, lasting for seconds. They are so intense that they make the sufferer grab his or her head. They generally occur infrequently in...
What is your approach to a patient with normal LFTS and high titer auto-antibodies suggestive of autoimmune hepatitis?
Normal LFTs in the setting of high titer liver autoantibodies would still lead me to request a Hepatology consult, even in the setting of a previously defined autoimmune disease, i.e., SLE or Sjogrens. After Hepatology assessment, and if there is a documented rheumatologic autoimmune disease, most o...
Is there any experience of using sarilumab instead of tocilizumab for steroid sparing effect in GCA during national tocilizumab shortage?
This is certainly a very good question, but unfortunately, we don't have an answer. The sarilumab GCA and PMR trials were unfortunately terminated due to the pandemic. I've heard of anecdotal experiences of the use of sarilumab but haven't used it myself (not sure if insurances would approve). Both ...