Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you anticoagulate a patient with an asymptomatic gonadal vein thrombosis on CT scan, found on surveillance imaging for colorectal cancer?
This is an area for which there are very limited reports (case reports/series) and certainly no small or large prospective studies. My bias is to initiate anticoagulation. It would be very important to look for an underlying malignancy or other explanation for the thrombus.
What is your approach to checking IgG levels post vaccination to detect common variable immunodeficiency in patients with systemic lupus?
I recommend that this type of workup for primary immunodeficiency disorders be done as soon as a diagnosis of systemic lupus erythematosus (SLE) is made. In other words, order quantitative immunoglobulins (IgA, IgM, IgG) plus IgG subclasses during your initial workup.Reasons being: Some primary immu...
How do you approach the usage of hydroxychloroquine in patients with rheumatologic conditions and baseline cardiomyopathy or heart failure?
This is an excellent and difficult question that parallels the recent posted question about the use of hydroxychloroquine (HCQ) in someone with an abnormal visual field. There is no question that HCQ can cause cardiomyopathy. There is no question that HCQ can prolong the QT interval. Fortunately, ca...
Do the level of positive lupus anticoagulant titers correlate with the risk of VTE?
The lupus anticoagulant test is either positive or negative. It’s not reported out at a titer. The test needs a two-step confirmation, the first being the addition of mixed plasma to rule out a factor deficiency and the second confirmation being the addition of phospholipids and showing normalizatio...
Do you offer immunosuppression to patients with CTD-ILD with concomitant well controlled HIV?
With the widespread use of highly active antiretroviral therapy (HAART), we have definitely seen an increase in long-term HIV patients who now live long enough and with enough functional immunity to develop CTD-ILD or autoimmune ILD warranting the use of immunosuppression. However, these patients re...
Do you utilize post-vaccination IgG titers to detect common variable immunodeficiency in patients who are about to start or are actively on B cell depleting therapy?
I have checked M-M-R, Td, and pneumococcal titers in patients with hx of infection and low Ig levels to see if they are making an immunological response. If any of these immune titers are low or the immunization is “due” by routine schedules, I recommend immunization and repeat testing in 6 weeks. T...
What would be the utility of calcium scoring for the evaluation of low-flow low-gradient aortic stenosis, and what cut-off values typically fall within the severe range?
Echo findings can be equivocal in as many as 40% of patients. Multiple studies have demonstrated a good correlation of calcium score and the severity of AS. A calcium score of 1300 in females and 2000 in men are defined cutoffs. In low flow low gradient AS with diminished EF a dobutamine echo should...
Do you recommend chlorhexidine mouth rinse for prophylaxis against oral complications in patients undergoing dental work who are immunosuppressed?
I have not, but would defer to dental/oral medicine colleague involved in patient care.Specifically in Sjogren's, I do not recommend chlorhexidine (CH). CH (antimicrobial) is indicated for gingivitis and periodontitis. Many of the formulations contain alcohol and dye, which are irritating for dry mo...
Are there any concerns regarding side effects in changing from denosumab to zolendronic acid or vice versa?
In patients with advanced solid tumors and bone metastases, the anti-resorptive agents, zoledronic acid (ZA) or denosumab (D) are administered to prevent skeletal related events (SREs). The key toxicity of concern is medication-related osteonecrosis of the jaw (MRONJ). While patient and oral health ...
Is there utility of modifying DMARD treatment in a seropositive rheumatoid arthritis patient with recurrent pleural effusions and RA nodules without other signs of active disease?
Modifying DMARD treatment in a seropositive RA patient without active articular disease may be useful when the patient has symptomatic noninfectious recurrent pleural effusions that are exudative requiring repetitive thoracentesis, frequent courses of systemic or intrapleural corticosteroids. Rheuma...