Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend genetic testing after a patient on clopidogrel has a stroke based on the results of the CHANCE-2 trial?
No, the data from CHANCE-2 (Wang et al., PMID 34708996) was based on a strictly Asian population and results need to be validated elsewhere for it to change practice.
What is the negative predictive value of a negative extended myositis panel in dermatomyositis patients?
The short answer is "not great, but it depends" since the more nuanced answer is contingent on: the constellation of myositis-specific antibodies (MSA) included on the panel, the nitty-gritty of how the commercial lab is checking the MSA included (this detail can change between vendors, or even ...
How do you manage psoriatic arthritis in patients who are planning to start treatment with checkpoint inhibitors for underlying malignancy?
This is a very important question, and I think rheumatologists will encounter cases like this more frequently as immune checkpoint inhibitors (ICIs) are being increasingly used. Roughly, 50% of patients with co-existing autoimmune disorders and malignancies have flare-ups of their autoimmune disorde...
How do you manage recurrent inflammatory pleural effusions in lupus pleuritis?
I'll stick to the immunomodulatory treatments and not discuss thoracentesis and pleurodesis for large and recurrent effusions. (These are rarely needed anyway, and I'd get the help of a pulmonologist). There really are no large study, or evidence-based proven therapies for pleural effusions and pleu...
What patient characteristics would lead you to opt for triple therapy versus double therapy in newly diagnosed PAH?
When treating patients with PAH it is essential to assess their mortality risk. Risk assessment is done using 2 tools that include the a) European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines (Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hyp...
Would you generalize the data from the CHANCE-2 trial to a broader clinic population given that the study was specific to Han Chinese patients?
I believe the results of CHANCE-2 (Wang et al., PMID 34708996) are generalizable to non-Chinese populations. CHANCE (Wang et al., PMID 23803136), performed in China, and POINT (Johnston et al., PMID 29766750), performed worldwide but excluding China, produced strikingly similar results in dual antip...
Do you routinely provide GI protection in the form of a PPI or histamine blocker for patients with immunobullous disease initiated on high doses of oral corticosteroids?
I honestly don’t unless a patient brings up GI symptoms during the visit. However, the literature does have clear recommendations. A recent JAAD CME stated that on any dose of prednisone for 3 months or greater, GI prophylaxis is needed for those who must be on a concomitant NSAID. It also recommend...
What workup do you do for patients who have PL-7 elevation when screening for myopathy?
In the literature, the PL-7 antibody has been associated with the antisynthetase syndrome and aside from myositis, interstitial lung disease (ILD). Patients with PL-7 autoantibodies are at high risk of ILD. Referral to pulmonary should be considered. One would also consider assessing pulmonary funct...
How do you interpret a mildly positive NT5C1A lab test in patients with hyperCKemia?
Seropositivity, in general, ought to support the clinical features of the given disease in the patient. In this instance, the patient should have selective medial forearm flexor weakness, quadriceps atrophy/weakness, and dysphagia (if in later stages). In the rare case that the phenotype has not yet...
How do you mitigate the risk of renal crisis from corticosteroids in a patient with UCTD?
I assume that this patient with UCTD has some scleroderma features (like a scleroderma-specific antibody) that are raising the concern for a renal crisis. If the patient is in the scleroderma spectrum, there probably is some risk, albeit probably low unless they have high-risk features (early, diffu...