Internal Medicine
Questions discussed in this category
Hgb is 8 and platelets 10. A very small PNH clone (0.08%) detected. No evidence of hemolysis. No response to steroids. All other anemia/thrombocytopen...
What medications do you use in patients who already have existing obesity and metabolic syndrome?
Do you defer or avoid use in patients with untreated simple hypertension or other cardiac history?
How do you balance the benefits of treating depression versus the risk of transition to mania? Do you consider stopping the medication as soon as the ...
For example, a patient with 100 WBCs in CSF with a peripheral WBC 43k/mm3 due to AML.
There seems to be little guidance on vitamin replacement in these patients. Vitamin K level < 50 yet PT/INR is normal. Is the vitamin K assay usefu...
Does the presence of ILD change your approach?
In light of data from Chang et al in J Neurol Aug 2024 showing that biomarkers such as LDH and troponin were associated with adverse clinical outcomes...
What medications bests treat Intermittent Explosive Disorder?
A female in her early 70s, total thyroidectomy, left 1.4 cm and right 0.7 cm tall cell variant papillary thyroid cancer with clear margins and negativ...
How do you view it relative to existing options like TNFi, IL-23, or IL-17s like ixekizumab?
For example, in patients with many swollen/tender joints, enthesitis, nail involvement do you expect particularly good response? Are there patients in...
Are you less likely to prescribe it for patients with dyslipidemia or autoimmune disease?
Can you elaborate on reasons for a non-quantifiable SPEP and how does one follow the paraprotein?
How do you balance concern for causing skin hypopigmentation with many of the traditional treatment modalities we have?
Is isotretinoin the only effective option?
If they have been on IV heparin for 3 days, for example, would you subtract those days from the recommended loading dose time?
Would your considerations change for a man vs a woman?
Given that Accutane can affect calcium homeostasis, would you recommend continuing Accutane or are additional steps or workups warranted?
Is there a target IgG level to aim for?
What should hematologists be aware of in monitoring these patients?
Do any special adjustments need to be made for any particular biologic therapies?
Thrombosis of the greater saphenous vein extending from SFJ to mid-calf, unchanged on follow-up Doppler imaging after 3 months of full dose rivaroxaba...
If so, what antibiotic regimens do you use?
In light of research that suggests SSRIs increase the risk of closed-angle glaucoma, Chen et al., PMID 28257449.
The disease is responsive to ablative lasers however laser treatments are not an option.
Butler et al., PMID 38587237
If their calcium score and stress tests are normal, would you still treat?
I'm uncertain why both individual parts can be so low/negative but together very positive. Is there an assay discrepancy, a false positive?
Considering a growing interest in the use of dextromethorphan for depression (Majeed et al., PMID 33682569).
Do you reserve biologics for more systemic involvement? When do you initiate biologics such as secukinumab?
Of note, there is ~150 cc small bowel left and no further surgery was offered.
If so, how often would you do this?
Specifically considering individuals with known mutations in MUC5B, TERT/TERC, etc
Or should they be continued on maximally tolerated GDMT?
What would be the best treatment options to minimize long term impacts related to cognition?
Cardiolipin was mildly positive and persistent after 12 weeks (29->28 MPL). No other significant provoking factors. The patient started on LMWH.
W...
For a patient whose sodium remains 142 despite water deprivation from 8 pm to 8 am, with urine osm of about 500, is further testing needed?
For example, baseline QT prolongation, elderly age group, or underlying heart disease?
Can you include both patient directed and clinician directed resources?
Are there specific scenarios where it could be considered?
Do you avoid certain antidepressants related to the risks on suppressing respiratory-drive which is potentially concerning in patients with high cord ...
How do you approach this in patients who are approaching or are over 65 given the contraindications of benzodiazepine use in geriatric populations? Wh...
Which factors would influence your decision?
A patient on meloxicam for LBP developed high, persistent fevers and no other symptoms. An IGRA, among many tests, was sent. The IGRA’s mitogen ...
Is there a role for increasing the dose if not yet maximum? (Hb ~8)
Can you explain when would you consider light chain amyloidosis work up with fat pad biopsy?
Pre-treatment troponin was mildly elevated, while ILR2 receptor, ACE, CRP, ESR were normal.
Do you favor specific medications or surgical interventions?
Clinical scenario where an indeterminate pathology on initial FNA was followed by a “benign” result on a 2nd FNA.
Do you avoid using these agents only in patients with history of medullary thyroid cancer or pancreatic cancer? Are there other cancer risks we should...
Would you send a CMV DNA PCR in blood, and if you elect to treat with anti-CMV medication, how long would you treat and what parameters would you use,...
Landoni et al., PMID 38865168
Cell counts are normal. Bone marrow shows grade 3 fibrosis. Spleen size continues to enlarge.
Typically, neurologists were taught to treat with triptans at the onset of headache pain. Do you still follow this teaching, or do you treat at the on...
Bone marrow biopsy does not meet criteria for MDS and no other identifiable cause of the cytopenias.
Family history is notable for CVA and early onset MI in nonsmokers, but no personal or family history of VTE. APLS testing is negative. Previously fou...
In light of the publication by Ganesh et al., PMID 39503052.
Do anabolic agents have a role?
What changes do you make to your treatment approach to adapt to this altered disease state?
Would you recommend repeat POEM, Heller myotomy, or pneumatic dilation?
How will you counsel patients about the risk and what strategies will you use to mitigate the increased risk of fungal infections see in the BE COMPLE...
Are you aware of any data regarding relative risk of molluscum contagiosum infection in reference to DMARDs/biologics?
If so, what diastolic parameters do you look at?
Viëtor et al., PMID 34503194
Are there any clinical trials underway to study additional therapies?
Patient had intolerance to methimazole and then developed agranulocytosis with PTU. FT4 is 2.9 (upper normal range is 1.7). I have started the patient...
SLE manifestations include arthralgias and cytopenias which are stable. Previously did well on methotrexate, but developed GI side effects. HCQ is on ...
Would you view this as a sign that disease is not adequately controlled despite labs and imaging suggesting no active vasculitis?
Is there a role in adjusting the medication doses to levels in seizure-free patients; or is it sufficient to just monitor patients clinically?
In light of the publication of results from the EPISODE study.
How would you approach anticoagulation in this situation? Does the presence of thrombocytopenia or hemorrhagic splenic infarcts change your manag...
For what duration and is there a preferred anticoagulation agent?
How would you sequence these therapies given approval for both?
The patient takes frequent flights for their job, with no prior history of VTE, and has already been taking measures for prevention including frequent...
How is it that I'm able to prescribe medications to patients (in my state) via legitimate mail order pharmacies that are located in a different state?...
Ferrell et al., PMID 38448791
Do you use steroids in the management of PJP pneumonia with severe hypoxia in HIV negative patients?
Data on the role of steroids in HIV negative patients with PJP has been conflicting.
There seems to be a wide variety of palliative doses used in clinical practice (8 Gy x1, 2 Gy x2, and 20 Gy in 10 fx). Do you have a preferred dose? D...
Have recent trials (TRAIN trial and HEMOTION trial) influenced your approach?
In light of the STOP-CAD study
Would you consider charging a small fee for managing C-2 prescriptions between appointments instead of requiring the patient to come monthly?
What specific settings and devices do you prefer to use?
Do you use them sequentially or together?
Labs with normal PT, but prolonged PTT (47 sec, ULN 40 sec) that does not correct on immediate mix. Lupus anticoagulant negative (DRVVT and hexagonal ...
For example, is captopril dialyzable?
What DSM-5 diagnosis and or diagnostic code do you use when treating this substance use disorder?
It seems clear that longer monitoring yields more AF detected. What is less clear to me is whether all ILR-detected AF is relevant and merits anticoag...
What about if the patient has mediastinal disease and ISRT is not an option?
How do you practically approach a tailored elimination diet in young patients with numerous food impactions and esophageal strictures who are intermit...
Some data showed early enteral nutrition improves outcomes in DKA. Some thought that enteral nutrition could counteract the insulin gtt.
Per the NCCN guideline for HR HD, if treated per OEPA-COPDAC, you can omit ISRT. This patient received treatment per AHOD1331, which recommends ISRT f...
Invited Professor Series Video: Volume Management and Access Troubleshooting in Peritoneal Dialysis - Claretha Lyas, MD
Would you change your radiation therapy treatment dose or volume if you needed to treat a chloroma? If a patient had a separate cancer (e.g., skin can...
Is it common to have IgA deficiency in absence of any recurrent infections?
I am not sure there is much efficacy for a regimen that does not include asparaginase. The patient received 2 cycles of P-GemOx, then was admitted for...
Do you monitor patients with CTAs or MRAs?
Do next generation sequencing results influence diagnostic and therapeutic decisions for patients with MDS?
https://www.cdc.gov/std/treatment-guidelines/neurosyphilis.htm
Have you found significant differences among SSRIs and SNRIs (e.g., paroxetine vs fluoxetine vs sertraline vs escitalopram vs duloxetine)? What data d...
Would having infarct expansion during hospitalization change your approach?
Would you anticoagulate for a fixed or indefinite duration? Would you recommend changing her contraception method?
Do you have a preference for biologics or phosphodiesterase inhibitors?
What would be your RT volumes and dose?
The basis of the question is that HFrEF trials enroll patients who have Class II-IV symptoms. If their LV systolic function recovers and they become a...
This is based on the recent publication by Bernstein et al., PMID 38551564 which investigated the increased rate of initiation of MAUD in the hospital...
Are your results different in adults whereby a particular trigger is often found and very helpful versus in children?
In patients who have decreased arousal after ischemic stroke, do you use amantadine or modafinil to aid with wakefulness and interaction with therapy ...
Would you label this as intermediate or high risk and treat with prophylactic or full dose AC? What duration would you treat for?
Assume the patient has infrequent bleeding events every few years, with use of FIX replacement for acute bleeds only.
Presuming good medication adherence.
Will either blocking IgE better or oral food desensitization be superior in increasing chances to outgrow a food allergy?
Most patients with PGNMID have no detectable disease in their marrow or blood and urine protein cannot adequately be monitored.
Do you generally recommend anti-diarrheals, dietary modifications, or consider this an unacceptable side effect and move to other therapies?
No prior hx of DVT/SVT. Negative LE doppler. Would you consider anticoagulating and at what dose, or favor close observation?
Do you consider starting Ursodiol? Do you perform routine abdominal ultrasound to monitor for cholelithiasis?
A large stroke in cortical regions might have a low NIHSS, while a small internal capsule lacune might have a large NIHSS. ICH risk is thought to be a...
UpToDate recommends Hydroxychloroquine for all SLE patients, but neutropenia is sometimes ascribed to HCQ rather than the underlying disease. What lev...
Is there a role for nelarabine and venetoclax in this setting?
Seems like AAP and AAAI support switch to 0.3 woolen at 55lbs and FDA and Woolen package insert at 66lbs.
Any thoughts on when to switch?
Is parasitemia >10% and severe hemolysis with Hb less than 7 enough to initiate this?
Does your approach change when using a long-acting injection antipsychotic with oral antipsychotic medication?
Would you recommend left atrial appendage occlusion with or without continuing anticoagulation? In light of Maarse et al., JAMA Neurology 2024.
If so, what dose and formulation of morphine do you prefer?The PACIFY COUGH trial utilized controlled-release morphine 5 mg BID, however the lowest do...
In light of a recent publication by Sun et al., PMID 39235816 on the BASIS trial for balloon angioplasty for ICAS.
USPTF and CMS guidelines differ in age criteria, and NCCN guidelines do not have an upper age limit.
The new SCCM guidelines suggest an upper limit of 200 compared to the conventional 180.
How do you approach increasing urinary citrate levels in a patient with recurrent calcium nephrolithiasis who has hypocitraturia non-acidic urine?
The patient has ongoing inflammatory arthritis despite methotrexate, apremilast, and jak inhibitor trials.
With the time intervals recommended after taking each medicine, I am wondering how patients should be counseled.
At what doses do you start? and how do you titrate therapy?
After what time period would you consider adding a second iron chelator?
Since ECHELON-1 trial showed an improvement in PFS (but not OS), are there any situations where you would replace bleomycin with brentuximab...
Would your approach differ through telemedicine for small ERs without access to onsite ophthalmology or neurology?
How have you accessed neurosteroids (allopregnanolone) for patients?
Odawara et al., Clinical Journal of the American Society of Nephrology 2024
Assuming patient already received an initial course of antibiotic treatment in response to a positive urine culture during routine screening early in ...
The ESC guidelines recommend obtaining at least three sets of blood cultures at 30-minute intervals before starting antibiotic therapy, each with 10 m...
In light of the INSPIRES trial publication.
Can nodular scleritis be a presenting manifestation of GCA?
Would a decrease in eGFR by more than 30% prompt you to consider decreasing or discontinuing these medications?
Do you discuss the risk of sickle cell crises with G-CSF? What about for patients with sickle cell trait?
Are there specific scenarios in which you employ BPAP with a back up rate?
Is this seen more with high dose vitamin D supplementation?
Caplacizumab is not FDA approved in pregnant patients, but has been used safely in isolated case reports.
Do findings from the REDOX Trial comparing 24 vs 15 hours of supplemental oxygen influence your approach?
Kunadian, et al., PMID 39225274
Do you use TNF-i or MMF?
The index question is: "neurosurgeons lately want to stop hydroxychloroquine prior to spinal surgery. Anyone allowing this for lupus patients and for ...
If a patient has received a kidney transplant for SLE-LN and is stable and doing well. Managed by their transplant team and on chronic immunosuppressi...
How would you adjust statin therapy in these patients?
See dapagliflozin drug insert form which states Farxiga is not recommended for patients with PKD.
What clinical significance does this have and how do you follow these patients?
In light of a publication by Sakusic et al., PMID 39102615 suggests an increased risk of ICH expansion in patients with heparin bridge compared to sta...
ESPRIT Trial
What do you think about the long term risk of AML with romiplostim with longer follow up studies? What about using other TPO agonists like eltrombopag...
When would you consider pomalidomide over bevacizumab?
Blood pressure targets for ischemic stroke and intracerebral hemorrhage are described in several guidelines. However, in patients with acute stroke wh...
Is there a role for non-myeloablative regimens?
In light of a study by Caroll et al., PMID 38820488 on epidural blood patches for patients with headaches attributed to SIH that were non-conforming t...
Is this managed as CTD-ILD with immunosuppressive +/- anti-fibrotic agents?
Would you adjust your approach based on the infarct size, symptom severity, or stroke etiology?
How do you evaluate for time off? Return to work? How do you deal with time off requests in the presence of non-adherence to treatment recommendations...
Al-Ibraheem et al., PMID 33731050
Would you be comfortable combining a TNFi with Rituxan in this patient?
Should uric acid levels be monitored regularly while on therapy?
Do you worry about additional increased risk of seizure for patients using medications to assist in weight loss such as GLP-1 agonists?
If they are already on a preparation that contains animal products, would you change it?
Soloman, et al., PMID 39225278
I have observed a trend where patients who are being tapered off of long-term benzodiazepine (especially in the geriatric population) prescriptions ar...
Are there characteristics which could help identify whether a follicular lymphoma might behave more indolently vs aggressively and inform treatment se...
The case prompting the question is a female in her late teens who was diagnosed with Class IV LN at her prepubescent age and was treated with HCQ and ...
Do you use different approaches in different settings (i.e., the ED vs. outpatient clinic)? Do you use different approaches for chronic vs acute suici...
Aluminum hydroxide/magnesium hydroxide (i.e. Maalox).
Have you encountered changes in prolactin, testosterone, etc?
Is there any concern for drug interactions of DMARDs and/or biologics with anti seizure medications?
What treatment regimen have you found most effective?
Do you recommend any lifestyle changes or prescribe oral azoles?
Any experience with topical r...
Thrombophilia testing, including JAK2 is negative. When would you stop anticoagulation?
Or would you sequence a different BTKi?
At the time of initial diagnosis, there was no clear CNS involvement. When it became clinically apparent disease was refractory to EPOCH, there was CS...
Would you consider testosterone therapy if he is otherwise asymptomatic?
How often do you recommend monitoring thyroid function tests in these situations?
What factors do you discuss when counseling the patient?
Cholesterol Treatment Trialists' (CTT) Collaboration
Do the presence of gastric varices and use of anticoagulation change the way you think about using these agents?
How do you balance between having a higher long-term blood pressure to prevent flow failure and leading to worsening of stenosis or occlusion from the...
Does a certain level of free light chain ratio reassure you against the possibility of AL amyloid? Is there a certain level that makes you more concer...
Hendriks, et al., PMID 38576380
Peripheral nerve surgical decompression, i.e., "migraine surgery" is a controversial procedure mostly being advanced by plastic surgeons. The evidence...
Ahmad et al., PMID 36106278
If not, has your practice changed to use vWF replacement therapy more routinely for perioperative or acute bleeding management? Do you still perform D...
The patient has a history of a lymphoplasmacytic lymphoma with a CR after chemotherapy but presented with a large frontal lobe mass that was biopsied ...
BMI>40
When do you stop luspatercept? How do you approach iron chelation therapy if the patient is currently on therapy?
Would you consider chronic RBC exchange versus HU?
Lazarus et al., PMID 26752337
Do you start/trial them on another biologic or just rely on topical therapies?
In patients with average of less than 5 respiratory events per hour, adequate sleep duration and hygiene confirmed on sleep log, absent cataplexy and ...
E.g., a patient with newly diagnosed CIDP who is wheelchair-bound.
Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?
Zha et al., PMID 35487459
Are there specific guidelines for managing this patient population?
Could the intrinsic inspiratory capacity and distribution of medication be different between the two routes?
Is there evidence for the use of varenicline, bupropion, or other medication therapies to assist in tobacco vaping cessation?
E.g., nasal, rectal, buccal.
Female in her early 40s with chronic spontaneous urticaria occurring consistently only at night for the past 4 years. Lesions develop only at night wh...
In light of Straub et al's comparative study of combination vs buprenorphine alone
Assume patient requires anticoagulation in the setting of acute thrombosis, with no need for IVC filter, but is approaching the end of her third trime...
What is your evaluation approach for RAI response? What cumulative dose do you use in practice for deciding a patient is RAI refractory?
Vasculitis involving aorta, subclavian, common carotid, SMA, IMA, renal artery, and celiac artery.
When do you determine SSRI therapy is unsafe to pursue in such situations?
What treatment do you initiate before you have a clear diagnosis?
Since free light chains are removed by dialysis and SPEP can also be impacted, is there a reliable way to monitor patients with ESRD and MM?
Okubo et al., PMID 38442744
Yue et al., PMID 38554774
Drug elimination is often helpful, but some triggers are not easy to identify because they are found in food items.
rWGS did not demonstrate any HLH definable or associated mutations.
ACORN Randomized Clinical Trial
How do you counsel patients in this scenario?
qPCR for BCR/ABL was negative. FISH remained positive.
If a patient is unable to tolerate peginterferon, is there any reason to think they may do better with ropeginterferon?
Would your management be different if the LVO was found on imaging without preceding associated symptoms?
Is your pattern for drug monitoring different if digoxin is being given for afib vs HFrEF?
Is APLS a contraindication to using interferon?
What is your preferred anticoagulation in patients with BMI >50?
Normal Vitamin D, bone scan showed osteoarthritis
Dao et al., PMID 38663923
Should some patients get 325 mg instead of 81mg at least for a certain amount of time, such as patients in the acute phase of ischemic stroke or patie...
If yes, if the assay shows they are a non-responder, do you switch to ticagrelor?
For B12 levels >2000-4000.
Hb at goal of 9-10
No clear inciting etiology found.
Would you consider dexamethasone +/- cytokine blockade (IL-1, IL-6, or IFN-g)? What do you think about the data for...
Nussbaum et al., PMID 38195100
Are the INRs reliable? In what scenarios would you not recommend POC INR use for warfarin monitoring?
Are these typically covered by insurance? Are t...
How does the presence of extra-renal manifestations influence this decision?
E.g. frequency of Bortezomib, dosing of Bortezomib, length of cycles.
Would you push for biopsy before deciding on treatment?
Considering the short half-life, at what point would it be deemed too late to administer any reversal agent, and to consider withholding it?
Assume thrombolytics are not indicated. Do you favor early DOAC transition after 24-48 hours of heparin gtt or do you favor LMWH for 10-14 days follow...
The patient is already on hydroxychloroquine.
Given nationwide shortage in vinblastine, several of my patients under active therapy are facing delays in their therapies. Is it appropriate to subst...
And have you ever seen it occur in isolation without any other manifestations of SLE?
CT changes are subsolid and ground glass nodules.
Liang et al., PMID 35900801
How would you counsel the patient given the drug interactions present?
Do you do additional workup for venous obstruction or any other different testing/evaluation?
Do you discontinue HCQ?
Do social or economic factors (i.e., relative cost of acquiring LMWH, the patient being injection averse) affect your decision to use DOACs?
Do you s...
Is there a factor XI goal that you target? Would you consider FVIIa products instead?
When do you switch to steroid-sparing medications? What steroid-sparing therapies do you prefer?
Would you still routinely ask for CIED removal, or would you pursue PET/CT for further evaluation and consider keeping CIED if PET/CT negative?
How do you guide what contraceptive type when asked by the medical team?
Chiung-Hui Peng et al., PMID 38436957
For example, would you offer 4 Gy x 5 fx (vs 24 Gy/12 fx) in a patient with isolated recurrent follicular lymphoma of the breast after RCHOP and maint...
Do you base the decision off of the acuity and course of symptoms? The degree of estradiol elevation? Other factors?
Do you empirically treat itchy patients -with a non specific rash- for scabies without obvious clinical findings for scabies?
In light of ANNEXA-I RCT results: Connolly et al., PMID 38749032.
Do treatments for osteoporosis have a large enough effect on tooth movement to make Invisalign less effective?
Additional risk factors could be family history of VTE or thrombophilia, such as antithrombin deficiency.
WBC and Hb values are normal, and normal JAK2, CALR, BCR-ABL.
In trapped lung, a fibrous peel over the visceral pleura restricts pleural expansion. Could transudative pleural effusions lead to this condition?
PARAGON HF trial, PMID: 31475794
When do you decide to hospitalize?
The patient has no extraocular features of a spondyloarthropathy and is on methotrexate. No active eye disease for past 1 year.
The REPRIEVE trial included participants who were between 40 and 75 years old.
The recently published SURMOUNT-OSA trial showed positive results
If yes, what is the rationale for doing that?
Can 25 OH vitamin D be converted to activated vitamin D outside of PTH mediated mechanisms in some organs?
Do the findings of the NICO trial influence your stance?
Are there specific mass features that would influence your treatment decision?
Do you use combination therapies such as betamethasone and calcipotriene foam?
Are there other mutations/biomarkers in CLL which may specifically predict for response or resistance to pirtobrutinib?
How often would you check labs during pregnancy or postpartum to monitor for worsening hemolysis?
In light of TIMELESS and TRACE-III trials.
No evidence for acromegaly or Pagets.
Specifically in O2-dependent patients? Have any dose/fractionation regimens been shown to reduce the risk of pneumonitis in this population?
Do you consider "bridging" therapy prior to transplant, and if so, what are your thoughts on the intensity of the chemotherapy?
If so, how long?
Miskulin, et al., PMID 38349776
If yes, which combination(s)?
Would you offer palliative (4 Gy) radiation therapy to the stomach mass vs. definitive doses (24 - 30 Gy) encompassing all of the disease?
This question is part of a collaboration with RheumMadness and is specifically in reference to: ULT During Gout Flare.
Given the side effect profile and risk of relapse off oral TXA therapy, do you prefer pulse dosing (i.e. 3 months on, 3 months off) or continuous ther...
Multiple recent trials have shown higher first pass success rate with VL over DL.
Should adult hemoglobin targets be different than pediatrics?
Do you first try adding topicals or UV? At what point do you decide to switch biologics and at that point do you try to class switch to a different MO...
Demay, et al., PMID 38828931
Do the findings of the PROPHY-VAP trial influence your approach?
If so, what is the typical duration?
The patient is actively breastfeeding.
In which situations or patient populations do you find this useful? How is it sterilized?
How do you monitor response and what do you consider a satisfactory response? Do you aim for a certain threshold of proteinuria?
Do the results of the recent study (Misset et al., PMID 37889107) showing reduction in 28-day mortality in patients with high neutralizing antibody ti...
(Since there is some suggestion that stains convert vulnerable plaque to stable calcified plaque and increase calcium score)
In a patient with no evidence of bleeding, do you use a platelet cutoff? Do you utilize genomic testing (eg CALR, MPL, JAK2, etc.) to decide on cytore...
Many patients are interested in romosozumab for "maximizing bone gain" and preventing future fractures. Some have had anabolic therapy with teriparati...
Do you routinely offer latent TB treatment in these cases?
Does this hold true when the patient has significant inflammation?
Do you extend the course of fidaxomicin past initial 10 days to at least 3-7 days after completion of antibiotics?
When would you phlebotomize patients with secondary hemochromatosis, such as due to NAFLD/cirrhosis?
HFE gene mutations in C282Y and H63D are negative.
Despite distinguishing between the three MPNs, results may not change management. There is controversy over whether to follow WHO criteria for d...
Ropeginterferon is now a preferred therapy for Polycythemia Vera (PV) as per a recent update to the NCCN guidelines.
What side effects do you highlight in conversation with them? How do you approach toxicity monitoring?
Do you favor gradual reduction in oxygen and pressure support with intermittent medication as needed or immediate extubation with peri-extubation medi...
Is there utility when classic inflammatory markers (ESR,CRP) or disease specific markers (C3, C4, dsDNA) do not correlate with patients disease activi...
The patient has very low urinary calcium despite calcium supplements, vitamin D used to be low now normal. Continues to have elevated PTH with normal ...
Are there patients that you find respond best to these therapies?
Patient is with past history of glomerulonephritis in remission after rituximab for the past 2 years. +MPO/P-ANCA
For example, in the setting of TBI, how do you guide the duration of the medical treatment?
Is there a role for oral vancomycin in these patients, or is oral vancomycin redundant if other routes of administration are being used (i.e intracolo...
Is there a role for oral antiviral therapy alone (as opposed to induction with IV) and for what duration? And is there a role for ongoing suppressive ...
Would you consider using cilostazol instead of antiplatelets?
Especially in light of the results of the randomized clinical trial published on 8/2024 in Jama Internal Medicine by Hayward et al., PMID 38587819.
I've seen a handful of fatal radiation pneumonitis associated with rapid steroid tapers by the non-treating physicians. How do you recommend prescribi...
Do you ever start mycophenolate without steroids?
MRI with muscle edema but biopsy pending. Would you consider this overlap myositis even though muscle enzymes are normal?
Would portal hypertensive gastropathy or colopathy sway you away from using it?
How would you consider anticoagulation vs antiplatelet therapy, or the addition of antiplatelet therapy for these patients?
Mother's insurance plan has a high deductible and phototherapy is inconvenient (family lives 50 minutes away).
For instance - any tips regarding coordination of care/transportation, associated lymphedema management, wound care, and pain control would be welcome...
Would you combine antibiotics with isotretinoin?
Patient in their 60s with TP53 mutation by NGS, treated 12 years ago with FCR, then at first relapse 2 years ago started ibrutinib. Bone marrow biopsy...
Would it be safe to resume and if so, when?
I found a study in which 32 patients continued on Botox for the treatment of chronic migraine. Only one had a miscarriage at 9 weeks and the rest seem...
For example, I have a patient who has frequent (monthly) large to medium joint flares (Knee, Ankle) with crystal proven disease. Did not tolerate colc...
I have an elderly patient with a history of biopsy-proven psoriasis on IL-17 biologic therapy. She has developed an intense itch without a primary ras...
How would your recommendation change if the patient has H63 homozygous mutation?
Or would you still offer penicillin G benzathine once weekly concurrently?
When would you consider a bone marrow biopsy?
Does it influence your choice of antithrombotic therapy? Do you perform serial follow-up imaging?
Thrombocytopenia is moderate (80-100,000 microL). No concomitant cytopenias present.
In light of meta-analysis data showing favorable outcomes in this normally excluded subset of patients (Katsanos et al., PMID 37775318).
EPIC-SR Trial
Is there management guidance on when to start after stroke onset?
Specifically, do you check for any of these: ACE, Vitamin D 1,25, serum lysozyme, soluble IL2 or Adenosine deaminase levels?
Asa et al., PMID 35291028
When would you consider using anticoagulation and for how long?
Are there specific safety or efficacy benefits associated with prolonged infusion times in this population?
With no high-risk exposure do you repeat quant gold?
Do you order blood work to evaluate for underlying dyslipidemia or other metabolic diseases?
Auguste & Bargman, PMID 36208963
I am aware that the radiological signs can be subtle or overlooked, or confused with a Chiari malformation, hence, I will typically review images with...
If so, is there a quantitative calcium score or a reported severity of CT coronary artery calcification that would lead you to start daily aspirin?
TRIANGLE study
What is your strategy for treating persistent headaches in the aftermath of subarachnoid hemorrhage?
Does your strategy change depending on whether or not it is a secured or unsecured aneurysmal SAH?
(preschool-aged patients)
Does your approach differ if the stenosis is symptomatic or flow-limiting?
Is there a role for booster vaccination and if so, how do you approach the timing when a patient is already on a biologic for immunosuppression?
Have you had success with deroofing or surgical excision? Is ILK the best option?
Seethapathy et al., NEJM
And when would you consider referral for staged/complex PCI instead?
Estimating blood loss from hemoptysis is not always reliable. The bleeding may be due to the PE itself. Is anticoagulation with any degree of hemoptys...
Individual times in the therapeutic range while on VKA treatment was not registered in FRAIL-AF.
If a patient progresses from discrete episodes (hours long) of mild vertigo with rare headaches, but associated migrainous features (photophobia and n...
Is there any evidence supporting the use of heparin boluses?
Besides HR variability how can we explain resolution of the intermittent LBBB with HF GDMT (especially with ARNI use)?
In light of published data from the CAPE COD trial...
Sabatine et al., PMID 28304224
For example, the patient may have other findings such as an elevated CRP. Would you diagnose SLE, or would you want to see other serologies or finding...
Is a BM biopsy a must when there is skin involvement?
If tryptase level is mildly elevated but less than 20 would you recommend a BM biopsy?
How long has it been back on the market? What is the typical cost for patients? Are certain compounding pharmacies regularly carrying it?
What is your approach to guiding ophthalmologists regarding our clinical suspicion for ocular syphilis and does the quantification of the titer help i...
The ASH 2020 guidelines have "recommended that adults with HbSS or HbSβ0 thalassemia be screened at least once for silent cerebral infarcts even ...
For example, a patient who is already on botulinum toxin injections, CGRP inhibitors, as well as an SSRI. Are there any new treatment modalities avail...
If so, how long would you hold? This medication is given for migraines as q3 month infusions and some data suggest that CGRP plays a role in immune-mo...
Confirmatory tests with DRVVT, hexagonal phase assay, and PNP are all normal. No bleeding history
In light of the evidence associating cerebral amyloid angiopathy (CAA) with subdural hemorrhage; Rivier et al., PMID 38147345.
What is the ferritin target that you would aim for? What would be your approach for a ferritin >500? When do you order an MRI liver for iron quanti...
Given pelvic RT is likely to induce ovarian dysfunction/menopause, would you consider systemic options?
And how would you monitor response?
Since the COVID-19 pandemic, increasingly we see management of acute cholecystitis with cholecystostomy tubes as opposed to surgery, even amongst pati...
What does it add beyond a serum electrophoresis or light chain testing?
Are there certain types of patients where monitoring immunoglobulins is parti...
In what clinical scenarios do you utilize post-cardiac arrest targeted temperature management (TTM)?
In the span between the HACA trial and the Targeted Temperature Management in Out-of-Hospital Cardiac Arrest study (Dankiewicz et al., PMID 34133859),...
After replacing Vitamin D, what will be your first treatment of choice? Labs including ALP and calcium levels are normal. T scores are -3 or above. Th...
How would you work up an elderly female with persistent anemia secondary to warm AIHA requiring almost monthly transfusion, with positive ANA,dsDNA (b...
Do you have a preference on the regimen or cycle number, and how and when do you assess response prior to transplant?
What criteria do you use to define steroid-refractory disease?
Does your management different by organ system involved - GI vs skin vs other?
Do you refer all patients with suspected LN, patients with confirmed LN, or patients with specific features (not responding to usual therapy, certain ...
Have you recommended supplementing less common supplements such as zinc or selenium?
Would you provide pentoxyphylline and vitamin E prophylactically after treatment? Is there a role for Boswellia? ACE inhibitor?
IgG4 manifestations include autoimmune pancreatitis and periaortic soft tissue mass.
Do your recommendations differ depending on the fragrance category (i.e fragrance mix I, II or balsam of Peru)?
Patient developed atrial fibrillation on Ibrutinib, severe fatigue and intolerance to Zanubrutinib and a maculopapular rash (grade 2) on Acalabrutinib
There is literature showing small changes in both free T4 and TSH (despite steady state) in the first few hours after ingestion of L-T4. In occasional...
The patient presented with a numb chin, more to the right of his face; an MRI did report mandibular nerve opacity, which is non-specific per neuro-rad...
For example, if patients are unable to receive continuous infusion from home health agencies, or if prolonged hospitalization is cost-prohibitive.&nbs...
What are the sources for this and are they reliable by today’s standards? Numerous case series report various abnormal movements but how reliabl...
Patient is a 41F and overall good surgical risk candidate.
If so, when? Does surgery need to be timed with last dose of Prolia injection?
Prior retrospective studies have suggested a lower rate of future catheter use with a backup AVF in place (Haralabopoulos et al., PMID 32852703).
What disease activity index do you find more useful and most practical in a busy clinical setting? How often do you assess it?This question is part of...
Does age influence your choice of regimen?
Aside from addressing the underlying case, is there a role for phlebotomy in secondary polycythemia such as in COPD or post-renal transplant erythrocy...
In the setting of requiring anticoagulation for atrial fibrillation and bioprosthetic valve, but also having severe vitamin K deficiency, would you st...
How do you navigate insurance coverage?
NCCN says "consider autologous HCT" while retrospective data seems to support SCT in most histologies like AITL
Do you add low-dose mycophenolate to use in combination with Rituximab in these patients?
If not, what can be possible causes for a postmenopausal woman to have FSH, LH < 0.3 with low E2, and being asymptomatic and doing well otherwise? ...
Visual aura is commonly described as a scintillating scotoma. In practice, there is a much wider spectrum of visual symptoms in the migraine populatio...
Have you changed your practice given BMT-CTN 1506/Morpho results?
Would you utilize maintenance therapy in patients who achieve MRD- remission?
If yes, is there a preference with MRI or CT technique?
Would you consider observation following surgical resection with negative margins? Would you recommend WBRT and/or ISRT? What would be your preferred ...
Does the approach differ if the tremor stems from essential tremor or Parkinson's disease?
How do you approach ongoing screening for TB in patients with history of treated latent TB, but have ongoing use of DMARDs and/or biologics given quan...
Would you continue R-CHOP or would you switch therapy?
A male patient in his 30s with two lumbar compression fractures (non-traumatic) and a Z-score of -2.6 in the spine, Z-score -0.5 in hips. History of 3...
From NCCN (Rectal MS-33): SBRT is a reasonable option for patients who cannot be resected or ablated.
What is the role of SBRT versus microwave ablat...
For example, how do you address tendency to "over-order" these tests in patients with common aches/pains but no structural abnormalities on advanced i...
For example, when switching from MMF to azathioprine, do you overlap the treatments as you lower the dose of one and add the other?
E.g., a patient has an intracranial hemorrhage after TBI with convulsive status epilepticus.
Are there any skin care products you would avoid in this population?
Patient with negative blood cultures, completed 6 weeks of IV antibiotics and vegetation persists. CT imaging without evidence of malignancy. No evide...
I.e., 20 minutes vs 30 minutes vs 1 hour.
How has this impacted your counseling and management?
How would you treat it?
Short-term glucocorticoids are often prescribed as "bridge" therapy to avoid ER visits. What else should we consider?
Would you consider this de novo DLBCL (unable to assess for clonality)? How would you handle prior anthracycline exposure?
How does graft source, conditioning regimen, and indication for transplant affect your decision regarding G-CSF?
Complete response was achieved after cycle 3. What extent of bone would you include?
Is there a specific tyrosine kinase inhibitor that you would prefer to use?
At the time of count recovery or do you continue it throughout induction and consolidation?
Comorbidities: morbid obesity, diabetes, hypertension
Patient does not have hypercalcemia.
And if so how soon after do you start?
Can a diagnosis of acromegaly be made with just an elevated IGF-1 level in patients with features of acromegaly?
How does the 2HELPS2B scoring tool play a role in your decision-making?
Given poor pulmonary outcomes in people with anti-PL12 antibodies, would you recommend more aggressive therapy? The patient was diagnosed with onset o...
And who would you not recommend to undergo surgeries?
The patient also has transfusion-dependent anemia secondary to the LGL leukemia.
Given CPX-351 was given to elderly patients ages 60-75 with a lower dose (60 mg/m2) Daunorubicin, can one generalize from this study to younger adults...
Is it different than early mobility that we always encourage?
NGS results are pending
What treatment modalities have you tried for "dermal hypersensitivity reaction"?
Is an MRI necessary to diagnose non-radiographic axial spondyloarthritis?
Conflicting data exists on whether Graves' disease would increase the aggressiveness of the concomitant thyroid cancer vs having no effect/correlation...
Would you still plan for lifelong anticoagulation in this scenario?
Is there a role in temporal artery biopsy?
Would you start with a baseline ultrasound and then pursue further workup such as fibroscan if fatty liver is present, or other?
We have seen 81 vs 162 vs 325 mg up to 1300 mg.
How about a distal occlusion? The patient was initially symptomatic but symptoms improved or mostly resolved.
Would you transplant a patient over the age of 70 with newly diagnosed myeloma? Does the risk category impact your decision?
The patient was recently diagnosed with pre-B ALL and is on day 10 of CALGB 10403. He is expectedly neutropenic as he received daunorubicin and vincri...
Would you follow an algorithm such as the one proposed by Hall et al., PMID 29940062?How do you decide between intrathecal chemotherapy vs systemic th...
Antifibrinolytic therapy alone +/- DDAVP?
E.g. young male, morbid obesity, with BMI >50
This question is part of a collaboration with RheumMadness and is specifically in reference to: Antibodies Before SLE.
Ferritin >2200, TSAT >80%
There are various formulations of intravenous iron; each with varying costs, test dose requirement, elemental dose, and number or time of infusions ne...
While follow up ultrasound is not usually recommended in provoked DVT, it often is done either for other reasons or by other physicians. Would this in...
Would you use with DMARDs/biologics or monitor?
How would you counsel the patient if he/she wants to continue on steroids?
Common thought is that FVIII may be used for differentiating coagulopathy in liver disease (normal to increased, from reduced clearance of VWF/FVIII) ...
Plasmapheresis first or IVIG first in GBS? What other treatment options are there for severe disabling GBS?
In what situations would you feel comfortable omitting RT to bulky disease in stage III/IV Hodgkin's lymphoma?
Initial tumor size:18 cm. Partial response was achieved after cycle 2 and cycle 6 of chemotherapy. Complete response (Deauville 2, size: 6 cm) was ach...
E.g., for a patient with myeloma, s/p induction therapy, and high-dose chemotherapy, followed by autologous rescue with inappropriate antibody respons...
What dose of RAI would you consider giving if recommended?
Though there is data to support using both hydrocortisone and fludrocortisone, it seems to be used rarely in clinical practice. A review publishe...
I.e. platelet count <30. Would your management change if HIT were only suspected rather than confirmed?
Do you consider pulmonary hypertension related to sarcoidosis to be an indication to start steroids?
Do you use biomarkers or PET scanning to stratify patients who may benefit most from therapy?
ANA patients referred to rule out CTD is a work-intensive, costly referral type. If they are positive for Anti-Dense Fine Speckled Protein 70 kDa (DFS...
If these patients were already prescribed non-selective beta blockers outpatient, do you recommend withholding these medications in the acute phase?&n...
What’s your preferred NSAIDs and next steps?
Practice is variable in the community, with some hematologists frequently prescribing ESAs for severe anemia that is mostly inflammatory. Do the risks...
Would you extend length of time for anticoagulation if the apex remained akinetic on surveillance TTEs?
If so, how long should OCPs be held to reliably trust the dex suppression test results?
In patients with chronic migraine and possible medication overuse headaches due to chronic narcotic use, what’s your strategy for those patients...
For example, in patients who are HbSAg negative, anti-HBc positive and HbSAb negative, does vaccination reduce reactivation risk?
Are there variations with different patient populations?
Or offer resection followed by adjuvant therapy?
While some have the practice of 90 days per SAMMPRIS trial, the lower rates of ischemic stroke in the medical therapy group were driven by events with...
Anemia is secondary to menorrhagia. No gynecologic interventions were possible.
Is there benefit to radiation on top of systemic therapy?
Low EF in the range of 30%
The patient is on mesalamine for Crohn’s and CellCept and HCQ for skin manifestations (currently on hold during workup). The infectious workup i...
This question is part of a collaboration with RheumMadness and is in reference to Pathogenic ANCA (RAVE Trial).
This is not an infrequent finding in outpatient neurology practice, often in the absence of any lacunar disease in the typical regions, though I usual...
Do you have a specific protocol you follow during the stress echo, and if so, what echo parameters are you using to evaluate for exercised-induced hea...
In other words, if offered wedge or segmentectomy, should SBRT be preferred? Does size matter ie if the lesion is < 3 vs < 2 vs < 1 cm? Does ...
PMID 35939577
Is the therapeutic purpose of the proteasome inhibitor to maximize total dosage per week or number of infusions per week?
Do you obtain serial cardiac PET scans?
Invited Professor Series Video: Volume Management and Access Troubleshooting in Peritoneal Dialysis - Claretha Lyas, MD
Invited Professor Series Video: Volume Management and Access Troubleshooting in Peritoneal Dialysis - Claretha Lyas, MD
Invited Professor Series Video: Volume Management and Access Troubleshooting in Peritoneal Dialysis - Claretha Lyas, MD
In FRAIL-AF, switching VKA therapy to a NOAC was associated with higher risk of bleeding in elderly, frail patients.
How should IVIG and either biologic injections or infusions be spaced?
Level >60%. No family or surgical h/o of bleeding but heavy postpartum bleeding.
PMID 37921461
Hb <11, low iron saturation (<10%), high ferritin (>900), and low reticulocyte hemoglobin equivalent.
Work-up was performed for isolated anemia which resolved to >11 g/dl after the reversible cause was treated.
Would your management be different in node + vs. node - patients? What would be your radiation volume and dose?
The patient has not responded/has contraindications to apremilast, colchicine, and adalimumab. When they were off azathioprine for 5 days in the past,...
Are you concerned about cases where radiation has to be started urgently before leukapheresis?
How do you determine duration of therapy for Tafamidis, or is it continued indefinitely for the patient?
Is it only done when heparin is used in an emergency?
No transfusion dependence but has hemoglobin in the 8-9 g/dl range.
If LHC is deferred, would you consider loading with plavix and treating for ACS for 48 hours (assuming acceptable bleeding risk) and optimizing GDMT p...
Would you consider further imaging like coronary calcium scoring or coronary CTA to further risk stratify them?
Have you had success with topical lovastatin or PDT?
And when do you consider (if ever) IGRT?
(Refractory to mycophenolate, azathioprine, and methotrexate. UpToDate suggests thalidomide or IVIG with mixed efficacy, while there are some case rep...
In a patient who relapsed following 2nd line transplant, how do you select CAR-T vs bispecifics vs non-T-cell-mediated therapies as outlined in NCCN? ...
Do you speak to different expectations re: ability to achieve PR/CR and/or how this will impact ability to get to later therapies for a patient with p...
Presuming the patient is not a transplant candidate due to comorbidities, PS, and age.
Given the risk of elevated ICP, would you attempt a brain MRI to further characterize the lesion? Or would CT imaging suffice prior to intervention?
Young, previously healthy male with normal growth presenting with two syncopal episodes. Currently, only symptom is mild fatigue. Labs showed: Cortiso...
What is the best treatment management of low grade early stage follicular lymphoma of the mesentery?
If the mesentery is widely involved with small lesions would this change your management? What if the patient was symptomatic?
And is there a preferred diagnostic test? Whenever cyclic hypercortisolemia is suspected, it is advised that evaluation should be repeated for months,...
If there are light chain deposits on the kidney, is that conclusive of MGRS?
If yes, how does that affect management?
If no, what are your indications for BM biopsy?
In FRAIL-AF, participants were switched from VKA to dabigatran, rivaroxaban, apixaban, and edoxaban.
Per the new data from the COMMANDS trial, Platzbecker et al., PMID 37311468
Would you offer WBRT + boost vs WBRT vs focal treatment/SRS.
https://www.jaad.org/action/showPdf?pii=S0190-9622%2824%2903329-2
Is this acute or long-term, and does it matter whether this is SBRT vs fractionated?
If so, would you start immediately or wait for the second set of labs to confirm before initiating blood thinners?
I’ve seen several such patients who have no secondary causes for bone loss, on adequate calcium/vitamin D, and compliant with denosumab who do n...
Should MTCTA be standard for anyone with LKN>=6h?
If so, for how long?
Is there an optimal bridging radiation dose for aggressive B-cell NHL undergoing CAR T-cell therapy?
What influences your decision to proceed with palliative vs. definitive, and standard vs. hypofractionation dosing regimens?
Per 2021 GCA Vasculitis Guidelines: low evidence, but conditional recommendation for CTA neck, chest, abd/pelvis. Is anybody following this or do you ...
What is the work up and what is the duration of anticoagulation if used?
Female is in her later 40s with surgical oophorectomy taking Sertraline 50 mg daily and prn Trazodone and Lamotrigine. Has some weight loss and fatigu...
Would you continue KEYNOTE-522 neoadjuvant therapy? The patient has a PMH of sarcoidosis with no stroke risk factors. No residual deficits.
Normally, waiting 6-12 weeks of therapeutic anticoagulation after an acute PE is suggested for any bronchoscopic procedure, however there is always a ...
E.g. Normal F8, VWF activity ~50%, VWF antigen ~100%, ratio 0.5 sent in a patient with positive bleeding history
Is there any clinical significance t...
Should this patient population be treated differently?
At our institution, we have started using EPIC to screen many patients for osteoporosis and ou...
Additionally, is it correct to assume that IV therapies might be preferred vs oral treatment given alterations in GI absorption in PLE?
Do you always avoid heparin/enoxaparin or rechallenge if antibodies are negative?