Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend using IL-1/IL-6 inhibitors in COVID-19 multisystem inflammatory syndrome in adults (MIS-A)?
There are very few published reports on the COVID-19 multi-inflammatory syndrome in adults (MIS-A), so most of the evidence is extrapolated from the experience of multi-inflammatory syndrome in children (MIS-C). MIS-A seems to occur very infrequently, typically in young adults, despite COVID-19 seve...
Would you place an IVC filter in a patient with an acute PE and an absolute contraindication for anticoagulation, but negative imaging for proximal DVT?
Good question. In this scenario, it would be reasonable to place an IVC filter. I would also image the IVC/pelvic veins in an effort to locate the origin of the embolus. A residual clot (depending on the size) may affect the approach to placement of IVC filter. Other variables include whether the PE...
How do you approach anticoagulation in patients with catastrophic antiphospholipid syndrome and thrombocytopenia?
Due to the rarity of CAPS, there are no evidence-based guidelines available and most treatment is empiric or based on expert guidance. Most would agree that the mainstay of treatment is anticoagulation, and the preferred anticoagulant is unfractionated heparin. In a recent guideline paper, therapeut...
How do you manage a delayed hemolytic transfusion reaction in a patient with sickle cell disease?
The diagnosis and management of a delayed hemolytic transfusion reaction (DHTR) requires a high index of suspicion. In those patients in whom a DHTR is suspected or confirmed, further RBC transfusion should be withheld unless absolutely necessary, and if then only with the most compatible RBC units....
Are you recommending tocilizumab for any COVID-19 patients?
The utility of IL-6 receptor inhibitors in COVID-19 is controversial, and I do not recommend its routine use in COVID-19 patients at this time. Although early observational studies of IL-6 receptor inhibitors in severe COVID-19 suggested potential benefits, an early RCT of tocilizumab vs. placebo (B...
What is your approach to treatment of lupus peritonitis?
Lupus peritonitis is difficult to treat and there are no evidence-based approaches, to my knowledge. I think ruling out other causes like malignancy, infection, perforation, thrombosis, liver disease, and renal/cardiac causes, as well as malabsorption and malnutrition, is the first step. Then I ...
How would you treat non-secretory myeloma in an inpatient setting?
This entity is rare with the use of free light chain assay. About 2% of all cases are non-secretory. In A Greek study, they were younger, less anemic, and had less often renal dysfunction and less extensive bone marrow infiltration. Presence and extent of bone disease were similar, however, hypercal...
When can defibrotide be discontinued before the 21-day treatment course is completed in a pediatric patient with SOS?
There is no data to support the 21-day use in everyone. Also, some patients might even need a longer course than the prescribed 21 days if manifestations are ongoing. A good general rule of thumb would be to continue (provided no bleeding or other toxicities) for 3-5-7 days post resolution of ong...
What is your approach for a symptomatic inpatient with locally advanced NSCLC who cannot have a PET?
These are tough cases. While we ideally aspire to have full (and congruent) staging information, this is not always possible.There are therefore competing pressures. Factors that favor AP/PA, 3 Gy fractions include 1) the need to initiate treatment rapidly given symptomatic burden and 2) the desire ...
What is your approach to platelet transfusion in heparin induced thrombocytopenia?
In general, I avoid giving platelets in intensely prothrombotic disorders, except in the circumstance of severe bleeding. Severe thrombocytopenia is uncommon in HIT, though DIC may occur in some patients. However, bleeding is relatively uncommon and platelets not generally necessary.