Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?
The approach to assessing hip osteonecrosis is to address the potential causes: Is there a history of antecedent trauma? Is there a family history of osteonecrosis? Is there a history of significant alcohol use? Is there a history of recent corticosteroid use? Is there a history of pancreatitis? Is ...
Would you consider the use of dual antifibrotic therapy (nintedanib and pirfenidone together) for progressive fibrosing ILD?
Pirfenidone and Nintedanib have different antifibrotic mechanisms of action, and emerging data suggests that these complex molecules may possess previously unknown pleiotropic properties. It is unclear whether a synergistic effect might be realized from combination therapy with these agents, and ind...
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 would not generalize to a broader population at this time but it is probably relevant in slow metabolizers of any ethnicity.
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...