Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you identify patients with false positive AcHR antibodies?
First of all, of course, one should look for the clinical correlation. Even a weakly positive AchR binding antibody is likely to be "real" (true positive) if accompanied by unequivocal clinical signs of MG, e.g., fatigable ptosis with positive ice pack test, or fatigable bulbar/limb weakness. Ideall...
What is your approach to discordant dsDNA testing, such as positivity to dsDNA by crithidia but negativity to dsDNA by other modalities?
What a great question with many facets. The information I provide is meant to be very practical. These answers are from the viewpoint of a rheumatologist and not an immunologist. I discussed this subject with Dr. Debra Zack, a rheumatologist/immunologist who is an expert with anti-dsDNA, and I had t...
When considering the use of DOACs in APLS, does the number of positive APLS antibodies influence your decision?
The number of antibodies is an important consideration.On the one end of the spectrum, I would not recommend any DOACs in a triple positive APLS (especially with arterial thrombosis). Having said that, I would not change treatment in a triple positive APLS patient if they were started on DOACs in th...
Do you always initiate hypercoagulable work up in a patient with recurrent stroke?
As always, this is a more complex problem than it appears. A history of both prior other thrombosis and family history of thrombosis is essential. Are there good reasons for the stroke and/or has it been worked out in past including carotid disease, atrial fibrillation, underlying malignancy, valvul...
How will you treat a young man with recurrent cryptogenic strokes with no identifiable cause, with MTHFR A1298C homozygous mutation and normal homocysteine level?
The genetic variant you report seems to be a SNP that, while it has been reported to be statistically associated with various diseases in GWAS studies, is not pathogenic. SNPs that are significant in GWAS studies have very small effect sizes that can be measured when considered in thousands of peopl...
Can lupus anticoagulant be positive despite a normal aPTT?
aPTT is one of the assays that may be abnormal in the presence of lupus anticoagulant, but not always. Usually, when screening for lupus anticoagulant, there will be a "special" aPTT assay used that is a bit more sensitive to detect lupus anticoagulant. There are several different aPTT-based assays ...
How do you determine if pulmonary hypertension is disproportionate to the severity of lung disease?
This is a question we faced on a daily basis in our PH clinic. Patients with parenchymal lung disease like COPD or ILD would get an echocardiogram that showed an elevated RVSP and/or RV dilation/dysfunction and will be referred to our clinic for PH evaluation. Alternatively, the patient already unde...
Would you check ANCA titers in a patient with a history of PR-3-ANCA glomerulonephritis in remission and a stable creatinine but with recurrent microscopic hematuria?
Not sure there is an easy answer to this. A patient in remission should not get a recurrence of glomerular hematuria unless the disease is active. A new onset glomerular hematuria would certainly make me worried about a relapse, some of which may be subtle, indicating "grumbling disease". The data o...
If a patient has potential arrhythmic-sounding syncope and a noninducible type 2 or 3 Brugada ECG pattern, have we excluded Brugada syndrome as the etiology for their syncope?
This is a complex question with a few nuanced components. The first component is qualifying an arrhythmic versus non arrhythmic cause of syncope. I would stress that this is based on generalization as there are no features that will provide absolute certainty for the nature of a single syncopal even...
Is there any benefit in maintaining statin or aspirin therapy in patients >75 years old with stable, multivessel ischemic heart disease in light of challenges encountered with polypharmacy?
This is a great geriatric cardiology question because it acknowledges that guidelines may not apply in an older patient with multiple medical problems and a complex medication regimen. The question further implies that treatment should be individualized and patient-centered. I agree with the questio...