Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there benefit to performing CVVH instead of intermittent hemodialysis for a patient with AKI secondary to rhabdomyolysis who requires renal replacement therapy?
My CRRT threshold is low, but a patient with AKI and rhabdo will have continuous K and Phos release from dead cells so I prefer a continuous therapy. This depends on the degree of rhabdo and the degree of AKI, but would lean towards CRRT for a moderate to bad rhabdo, same for TLS and same with acute...
Do you intensify the dialysis prescription for patients with end stage kidney disease who develop uremic pericarditis despite regular dialysis sessions?
This was what we did 30 years ago, it did not work. I remember as a fellow there were two explanations for pericarditis in a renal patient, uremic pericarditis if they had not started RRT and something else ("viral etc) if they were on RRT. This was based on the assumption that RRT was good enough t...
Would you treat a hemochromatosis carrier with IV iron if they have iron deficiency anemia in conjunction with elevated ferritin?
This scenario, with numbers like these, suggests another underlying issue. A carrier of hemochromatosis cannot typically have a ferritin level of >900 due to hemochromatosis. The TSAT of <10% corroborates this statement. If this patient is real, they likely have an underlying inflammatory disorder ...
What is your approach to monitoring patients with cardiac sarcoid while tapering immunosuppression?
Monitoring of patients with cardiac sarcoidosis (CS) is critical to optimizing therapy and improving outcomes. Once a decision has been made to institute immunosuppressive therapy, it is important that the efficacy of therapy is demonstrated and that the duration of therapy is guided by the response...
Is there a role for systemic therapy for a patient with scleroderma sine sclerosis, with esophageal strictures and Raynaud’s syndrome, but no pulmonary involvement?
We don't have any evidence that immunosuppression (assuming that is what you are referring to) would play a role in the treatment of the esophageal disease or the Raynaud phenomenon. Also, we don't have any data to suggest that this would have any overall long-term "disease-modifying" effects. So in...
Do you start aspirin for patients with incidentally found intracranial vertebral stenosis?
I'm not aware of any clinical trial evidence, but in this scenario, I would probably start with baby aspirin.
What considerations do you take when evaluating a patient for kidney transplantation who has a history of kidney disease and an abdominal aortic aneurysm treated with past stenting?
If the external iliac vessels are spared then the patient does not have an absolute contraindication to transplantation. The risk factors associated with the AAA will need careful review, e.g., smoking, cholesterol, hypertension, CAD, and other vascular diseases, and mitigated if possible. Anecdotal...
For a pedunculated rectal polyp found to be adenocarcinoma after endoscopic removal, with PNI as the only adverse feature, would you recommend additional treatment such as surgery or chemoradiation?
Yes
Should colchicine be considered in patients with ischemic heart disease and persistently elevated hsCRP despite statin and aspirin therapy and appropriate physical activity?
How would you treat a young patient who presents with coronary vasculitis and aortitis with persistently positive MPO but no other features of AAV?
Once infectious causes such as syphilis have been excluded, the most common causes of the combination of aortitis and coronary vasculitis would be Takayasu arteritis and IgG4RD. However, AAV can cause both aortitis and coronary vasculitis (albeit infrequently). Therefore, if there are no features of...