Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to the monitoring and management of a never-smoker with respiratory symptoms and a nonspecific ventilatory pattern on pulmonary function testing?
In the RETHINC trial, inhaled dual bronchodilator therapy did not decrease respiratory symptoms in symptomatic tobacco-exposed people. We still do not know how best to address symptomatic people with PRISm or those with or without a smoking history and respiratory symptoms without obstruction on spi...
Do you stop PPI when starting patients on immunotherapy?
Proton pump inhibitors (PPI) are commonly used in cancer patients and may affect the gut microbiome by altering gut pH. The gut microbiome plays a critical role in modulating the therapeutic effects of immune checkpoint inhibitors. PPI use in patients treated with immunotherapy has been associated w...
What is the difference between Multisystem Inflammatory Syndrome in Adults (MIS-A) and MAS/HLH?
Macrophage activation syndrome (MAS)/hemophagocytic lymphohistiocytosis (HLH) are cytokine storm syndromes (CSS) associated with various infections, rheumatic conditions, and hematologic malignancies (among other etiologies). Multi-system inflammatory syndrome in adults (MIS-A) is a discrete entity ...
How do you approach a thoracic lymph node that is highly suspicious on CT and PET but negative on EBUS in patients with NSCLC?
Our institution is very privileged in having a very large, highly expert team of interventional pulmonologists. In the cases where we are conflicted over how to interpret imaging of concerning lymph nodes, and where we have had the chance for a deep dive at tumor board and accompanying expert radiol...
Do you adjust immunosuppression in lung transplant recipients diagnosed with COVID-19?
Adjustment of immunosuppression in the setting of infection is center dependent after transplant. At our center, we typically only adjust if needed, other centers will empirically stop Mycophenolate. We typically monitor the white blood count and Prograf levels daily. If the patient we adjust the Pr...
Do you feel comfortable using azathioprine for dermatomyositis in patients with cirrhosis?
Azathioprine can cause liver damage, albeit this is a rare complication and usually asymptomatic. Therefore, I would probably avoid it in cases of liver cirrhosis and try other medications, like mycophenolate, IVIG, tofactinib. In either case, I would consult at the same time with the patient's hepa...
At what point do you recommend muscle biopsy in the workup for myositis?
Muscle biopsy is generally recommended and useful in most cases of suspected inflammatory/immune myopathy; accurate pathologic diagnosis is imperative for prognostication, identification of comorbid conditions (e.g., cancer, interstitial lung disease, arthritis, etc.), and treatment decisions. Histo...
To what extent does the degree of thrombocytopenia correlate with the severity of cirrhosis?
The degree of thrombocytopenia in cirrhosis is dependent on multiple factors. Decreased production of thrombopoietin by the liver. This can usually be overcome by the administration of a TPO-receptor agonist IF an increase in count is needed for a procedure and there is at least a week to prepare. ...
How do you approach relapsing ANCA-associated vasculitis in a patient who has already undergone kidney transplant?
In a very individualized way (What has the patient been treated with before? What is the current transplant immunosuppression? etc.) and in conjunction with a transplant nephrologist. One could imagine re-induction with rituximab would work in many cases but specifics about each individual case will...
How long after starting anticoagulation would you remove an IVC filter in a patient with a DVT presenting with stroke and PFO which is now closed?
This can be a complex scenario. The first question to ponder: if the patient could receive anticoagulation (a/c), why was the filter placed? Let us assume that there was a short period of time from the initial presentation of stroke, during which anticoagulation was contraindicated and there was a l...