Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What workup and initial treatment should be considered for suspected autoimmune myelofibrosis?
Autoimmune myelofibrosis is rare and most often described in association with SLE, either concomitantly or during the course of the disease, and usually with depression of one or more of the blood counts. It is a rare occurrence with the proviso that since myelofibrosis is a reactive and reversible ...
How would you approach a rising PR3 in a patient with limited GPA who is currently asymptomatic on methotrexate?
This is an important question because ANCA testing is frequently used in the monitoring of disease activity in AAV. Unfortunately, ANCA is a much better diagnostic test than a disease activity biomarker. Multiple studies have looked at the utility of ANCA in monitoring disease activity finding that ...
What is your approach in a patient who develops interstitial lung disease while on anti-TNF therapy?
I would stop the TNF antagonist and never use this class of drugs again in the patient. In fact, I generally stay away from TNF antagonists in RA patients with any sign of pre-existing lung disease. The experience of Nakashita et al., PMID 25125479 is highly informative and parallels my experience, ...
Do you counsel patients with an ileostomy about significant diarrhea when treating the pelvis with radiotherapy?
For patients with an ileostomy, they should be told that they are expecting to have an ileostomy output of approximately 1 to 1.5 L per day immediately after recovery from surgery. However, the output may decrease over time.If a large amount of small bowel is in the pelvic radiation field and/or the...
How do you approach the workup for patients with hyperCKemia and positive NXP2 with no clinical symptoms?
I would approach it like any case of hyperCKemia: verify that the high CK occurred in at least two measurements 24 or more hours apart, not shortly after intense physical exercise, get a careful history and exam with special attention also to skin and nail findings. If hyperCKemia is persistent get ...
When performing salivary gland ultrasound for Sjogren's, what else do you include in the differential diagnosis?
Sarcoid Amyloid
What is the role of kyphoplasty or vertebroplasty in patients with osteoporotic spinal fractures?
Vertebroplasty and kyphoplasty can be grouped together as vertebral augmentation. They have a single indication: To reduce pain arising from a documented vertebral fracture. Kyphoplasty has an inflatable balloon and in theory, can improve vertebral height prior to introduction of the cement. I am no...
What steroid regimen do you employ in the treatment of patients with post COVID-19 pulmonary fibrosis?
I don't use steroids for post-COVID fibrosis. Not only have I not seen steroid-responsiveness in this setting from an anecdotal standpoint, but previous data on steroids in non-COVID pulmonary fibrosis seems clear about the potential harms (e.g., PANTHER trial). If there is a large proportion of gro...
In antiphospholipid syndrome with recurrent strokes, would you consider adding antiplatelets to warfarin?
This is a good question, especially noting the high rate of recurrent thrombotic events in non-treated patients with antiphospholipid syndrome (up to 29% if untreated, but still significant among treated patients, especially after an arterial event). Edit: to jump to the punchline, I favor adding AS...
What is the recommended management approach in regard to diagnostic evaluation and treatment for patients with homocystinuria and cerebral thrombosis?
I think it’s reasonable to start anticoagulants for 3 to 6 months after getting complete blood test panels for hypercoagulation states. Be careful while interpreting abnormal hypercoagulation test results since many times you may see abnormalities. I would also repeat them within 3 months when the p...