Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach use of DMARDs and/or biologics for inflammatory arthritis in patients with a history of seizure disorder on anti-epileptic medications?
Polypharmacy should always be a worry in our treatment of rheumatoid arthritis. Fortunately, the biologics, reflecting their immunoglobulin framework, are rarely a concern for drug-drug interactions. This is in contrast to small molecule inhibitors such as methotrexate, leflunomide, and the jak inhi...
Do you continue TNF inhibitors in patients with a new diagnosis of CLL?
If the patient does not require any treatments for CLL that are potentially immunosuppressive, I would continue TNF-inhibitor therapy in this setting. It is always helpful to discuss the case with the patient's hematologist/oncologist to make sure everyone is comfortable with the plan.
Would you start ASA and/or statin therapy on an asymptomatic patient noted to have incidental pathologic Q waves on EKG, assuming no prior history of ischemic heart disease?
I would start with a thorough H and P and comprehensive risk evaluation with necessary screening including blood work, at least a stress echocardiogram if not a full echocardiogram in addition, and also offer Calcium scoring. Given more details are not given regarding the patient's age and functiona...
How do you approach peri-operative management of anti-resorptive therapies such as denosumab in patients undergoing joint replacement?
This is a very practical question. I think it is fine to continue the denosumab on a regular 6-month schedule for patients undergoing joint replacement. The reduction in bone turnover should not affect the implant. In fact, with denosumab, there is a small anabolic effect with each treatment that mi...
Would you evaluate for thrombophilia in patients with incidental splenic infarcts in the setting of known cirrhosis, portal hypertension, and splenomegaly?
When approaching splenic infarction, one question is to attempt to discern if the infarction is due to venous thrombosis (e.g., in the splenic vein) and subsequent congestion or due to arterial thrombosis (e.g. in the splenic artery), which is much more common. Talking with an expert diagnostic radi...
What is the preferred management plan for patients diagnosed with a concussion in the acute setting?
For acute concussion, if sports related, they should be removed from play immediately and not allowed to return for the duration of the game. For any cause of concussion, it is generally accepted to avoid NSAIDs and use acetaminophen for the first 24 hours if needed for headache. After the initial 2...
Would you switch azathioprine to a different immunosuppressant if a controlled patient with SLE develops melanoma and/or non-melanoma skin cancer?
This is a difficult question with no definitive research-proven answer. Clearly, most of our drugs do enhance the chance of melanoma and nonmelanoma skin cancer. If one does a literature search the only one of our drugs that has not been reported to increase the chance for relapse of melanoma is Tac...
What are the current clinical practices for TEE to guide cardioversion and anticoagulation duration post-cardioversion for Afib/flutter in patients following left atrial appendage closure?
Right now, there is not a great deal of data to guide us to answer this question. In general, the safest thing from a stroke prevention standpoint would be to adhere to the same guidelines that we would for patients without left atrial appendage occlusion devices. However, of course, most of these p...
How do you approach treatment of vasospasm after AVM rupture?
In my practice, ruptured AVMs are managed in a way somewhat similar to aneurysmal SAH rupture. Initial DSA evaluates the AVM’s angioarchitecture and identifies high-risk features, such as intra-nidal or branch feeder aneurysms. These high-risk features are addressed during the acute phase of managem...
In what clinical context would you consider offering first time catheter ablation for symptomatic atrial fibrillation in patients with advanced heart failure, as opposed to a trial of antiarrhythmics and/or cardioversion?
I would favor first-time catheter ablation in patients with advanced heart failure as a way to improve LVEF%, symptoms, reduce risk for recurrent hospitalizations, and decrease mortality. Many patients with advanced heart failure have an enlarged LAVI, so DCCV will only be a temporary solution and a...