Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How soon after completion of salvage RT to the prostate bed do you allow urethral dilation?
In my experience, anastomotic strictures do not resolve spontaneously or with treatment interruptions. In part, the answer to this question depends on how symptomatic the patient is and how close you are to the end of treatment. If the patient is totally obstructed or close to it, you're probably go...
In a patient with inflammatory orbital disease without a discrete mass to biopsy and recent bisphosphonate use, how much additional workup would you do if basic labs, urine studies, ANCA serologies, thyroid studies, chest imaging (to r/out sarcoid) are normal, before concluding that the process is likely secondary to bisphosphonate use?
Bisphosphonates are a known but rare cause of orbital inflammation. An intravenously administered bisphosphonate is far more likely to cause this compared to an oral drug. There is usually a close temporal association between taking the medication and developing the inflammation. The diagnosis is on...
How does one interpret persistently positive lambda light chains on serum immunofixation but without measurable serum monoclonal protein and a normal light chains and ratio?
I would probably also check a 24 hour urine protein electrophoresis with immunofixation to evaluate if any significant and measurable monoclonal proteinuria that would make me more worried about SMM, MGRS, or amyloidosis. Would check urine protein/creatinine ratio to evaluate protein excretion for t...
How do you decide on initiation of treatment with steroids or immunomodulatory therapy in patients with statin-induced myopathy versus statin-induced autoimmune necrotizing myopathy?
In the setting of limited experience, in patients with statin induced necrotizing polymyositis (HMG-CoA reductase antibody mediated necrotizing myositis), the best approach is typically steroids (prednisone 20mg or so), IViG 2gm/kg every 4 weeks, and potentially CellCept at 2000 to 3000mg per day, w...
What are best practices for engaging with multidisciplinary colleagues to ensure patients with earlier stage NSCLC are being appropriately considered for novel adjuvant therapies?
All post-operative lung resection patients are discussed at our multidisciplinary tumor board. As a collective group and especially with input from medical oncology colleagues almost all patients will be considered for adjuvant therapy if they are candidates.
How do you approach the management of immunosuppression in patients with lupus nephritis that go on to dialysis?
It depends entirely on their disease status and profile. It is not unusual for patients to have decreased disease activity when they go on HD. If there is still clinical activity though, I maintain them on immune suppressives and prefer mycophenolate mofetil (a major anti-renal transplant rejection ...
What are your preferred treatment options for patients with cholestatic pruritus who do not respond to light therapy?
Great question as in my experience phototherapy does not have high success rate for this. Agree that rifampicin can help quite a bit! Here is an algorithm you might find useful: Initially treat with a bile acid sequestrant such as cholestyramine (total daily dose of 4 to 16 grams) If this does no...
What are your considerations for peri-operative anticoagulation in patients with a mechanical heart valve undergoing a major noncardiac surgery?
For a patient with a modern (e.g St Jude bi-leaflet) mechanical valve (with or without AF) and who does NOT have a h/o of stroke or TIA, the available evidence suggests that "bridging" may have more risk than benefit: See Kovacs et al., PMID 34108229 and Siegal et al., PMID 22912386. Based on this e...
What is your approach to evaluation of underlying autoimmune disease in patients with bilateral scleromalacia?
Scleromalacia perforans is an uncommon form of scleritis wherein there is scleral melt in an otherwise white/quiet appearing eye. The most common systemic association for scleromalacia perforans is with long standing rheumatoid arthritis. Other etiologies of scleritis should also be considered: syst...
Does testing for elevated serum homocysteine have any relevance in thrombophilia management?
Homocystine levels is part of a DVT workup. Although rare, it is a factor in DVT risk. The gene mutation in MTHFR contributes to the elevation and the mutation frequency is extremely high. However, elevation is almost never seen due to added and natural folate in the diet.