Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
What criteria do you use to consider pleurodesis vs indwelling tunneled catheters in patients with malignant pleural effusion?
There are typically three approaches that are used for the management of recurrent malignant pleural effusions. The first approach is to perform repeated thoracentesis. This may be acceptable if there is a significant duration of time between recurrent symptomatic pleural effusions. The other two ap...
How do you counsel patients regarding prognosis following a diagnosis of IPF?
Are you using NAC in lieu of hypertonic saline amidst the current shortage of hypertonic saline in patients with either CF or non-CF bronchiectasis?
The Mogayzel and colleagues guidelines for maintenance of lung health do not recommend for or against NAC in the treatment of CF Lung disease. In contrast, they do recommend the chronic use of HTS. Mogayzel Jr et al., PMID 23540878In CF and Non-CF bronchiectasis, my first choice is inhaled hypertoni...
With the approval of oral JAK inhibitors such as Upadacitinib for atopic dermatitis, how are you considering its safety profile in comparison to traditional immunosuppressants such as prednisone, methotrexate, azathioprine, and mycophenolate?
In every treatment situation, we need to help the patient understand the potential benefits and potential risks of a medication. In my opinion, Upadacitinib is in a completely different category than traditional immunosuppressants such as prednisone, methotrexate, azathioprine, and mycophenolate, si...
Would you give antithrombin concentrate for surgical VTE prophylaxis in case of congenital AT deficiency?
There is no role for routine antithrombin (AT) infusions. In selected situations, during high risk e.g. periods surgery or labor and delivery, etc when anticoagulants are interrupted, AT replenishment is reasonable.
How would you manage someone with antithrombin deficiency who has recurrent VTE on a DOAC?
There are no large scale controlled studies demonstrating outcomes of use of oral direct-acting anticoagulants (DOACs) in patients with hereditary thrombophilia. One can find published case reports demonstrating success, but the 'failures' likely do not get published. The general approach would be t...
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
I would refer to the following article that provides the most up-to-date definitions (including the definitions for low-level antibodies) and risk stratification tools including APL-S and GAPSS that are developed for people with autoimmune conditions. The article also discusses the levels of evidenc...
When would you consider a workup for C. diff in a patient with diarrhea under-going concurrent chemoradiotherapy for rectal cancer?
Good question – and hard to pinpoint a strict answer. I think any time the diarrhea is out of proportion to expectation (i.e., very early in RT course), clinically significant (dehydration, etc), and not controlled or responding to anti-diarrheal medications, especially in the setting of C. diff ris...