Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you interpret a low VWF activity/antigen ratio, when both activity and antigen levels are above 50%?
This discrepancy is most likely caused by heterozygosity for a VWF variant that either causes VWD type 2M, with defective binding to GPIbalpha, or interferes with the binding of ristocetin, assuming that the activity represents ristocetin cofactor activity. The presence of a bleeding history suggest...
Is there an indication for adrenalectomy in patients with subclinical Cushing syndrome and adrenal nodule?
The short answer is "Yes". The indications for surgery depend on a number of factors, including the number of comorbidities and their severity and the degree of the HPA axis abnormality (1 mg DST and baseline ACTH/DHEAS level). We tend to be more aggressive with surgery in younger patients, although...
What further work-up (if any) should be considered in patients with pituitary microadenoma and stigmata of Cushing's disease but low ACTH and repeatedly normal plasma, urinary, and salivary cortisol levels?
I would obtain history of alcohol intake, depression and anxiety, and will assess the pituitary adrenal axis by overnight dexamethasone suppression test.
Is it possible to have undetectable cortisol levels in secondary adrenal insufficiency?
Yes, you can certainly have undetectable cortisol in central AI. Low IGF-1 and low-normal FT4 would suggest hypopituitarism. Do you have a testosterone level? I would perform a GH stimulation test. An abnormal test would confirm pituitary pathology. Before this, however, I would carefully investigat...
Based on results from the VOYAGER PAD trial, when would you consider the primary use of rivaroxaban with aspirin +/- clopidogrel as opposed to conventional aspirin +/- clopidogrel in patients undergoing lower extremity revascularization?
Based on the results of the VOYAGER PAD trial, I would consider using rivaroxaban with ASA before undergoing revascularization.
What workup do you initiate for thoracic outlet syndrome?
This is a long and complicated topic and I would propose to read the Consensus reporting standards for thoracic outlet syndrome published in 2016 by the Society for Vascular Surgery (see below). I will summarize a few key points from the article: Diagnosis of neurogenic TOS is basically CLINICAL, an...
What management do you recommend in patients with backpack palsy?
Backpack palsy is a well-known brachial plexus injury, often affecting the upper/middle trunks, resulting from carrying heavy loads on the shoulders and upper back. I used to believe that it is typically a stretch injury causing transient neurapraxia (demyelination) with minimal axonal loss and an o...
What is the preferred imaging modality to evaluate subaortic membranes in patients with aortic valve disease?
Transesophageal echocardiography is the preferred modality for evaluating subaortic membranes, especially if transthoracic echo is equivocal.
How would you interpret a positive single specific markers like SSA or SSB in setting of working up an connective tissue disease, especially when ANA is negative?
Ha! Good question. And this is an issue I literally just talked about with our residents during an autoimmune labs lecture that I give. If you have a negative ANA by IFA (immunofluorescence assay), the sensitivity of such a test is extremely high (99%) as hundreds of antinuclear antibodies are scree...
How do you manage drug-drug interactions between oral anticoagulants and the ARSI agents such as apalutamide and enzalutamide?
Commonly used oral anticoagulants, such as apixaban, rivaroxaban, and warfarin are substrates of hepatic cytochrome P450 enzymes (CYP). Co-administration of an AR signaling inhibitor (ARSI) variably affects the concentration of those drugs depending on the effect on the type of CYP enzymes. For exam...