Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to secondary prophylaxis for C difficile infection during concomitant antibiotic use in a patient with a history of C difficile infection?
We have been restricting secondary prophylaxis to those patients with severe protein malnutrition, receiving immunosuppressive chemotherapy, generally at the extremes of age who require unavoidable systemic antibiotics that cannot be withdrawn. Based on the 2024 paper by Ronza Najjar-Debbiny et al.,...
How would you treat ESRD patients on hemodialysis with recurrent AV fistula thrombosis found with low protein C activity?
I assume that the patient described in the vignette has a negative family and personal history of VTE. PC (and PS) deficiencies are relatively common in ESRD patients. The low levels are thoughts to reflect a combination of true (acquired) reduction and the assay interference rather than true defici...
Does IVIG or subcutaneous Ig interfere with monoclonal antibody therapy (i.e. dupilumab, infliximab, rituximab, etc)?
I definitely agree with Dr. @Dr. First Last concerns. For what it’s worth, I use a lot of IVIG in combination with monoclonal medications in my myositis clinic, and have anecdotally noted multiple instances in which I feel that the efficacy of one of those monoclonals seems to have been worse when t...
How would you manage a patient with Takayasu arteritis controlled on TNFi who develops erythema nodosum that is only partially responsive to NSAIDs?
Erythema nodosum and pyoderma gangrenosum (as well as erythema induratum) are well recognized as cutaneous manifestations of TAK. Unfortunately, we do not know how often cutaneous and the vascular disease are decoupled from each other due to a lack of available data. Most case series document associ...
What is your approach to therapy in patients with progressive Scedosporium pulmonary infection who are not candidates for surgical debridement?
Scedosporium species are increasingly common clinical isolates in patients with bronchiectasis (both CF and NCFBE). There are precious few publications describing these infections in immune-competent hosts, but it seems that these infections tend to be symptomatic (rather than asymptomatic colonizat...
Would you consider using DOACs as a bridge to warfarin instead of heparin or LMWH?
I would feel very comfortable bridging with apixaban, given its relatively short half-life and fairly quick absorption. I think it is very similar to bridging with Lovenox. More importantly, it usually takes at least 24 hours until heparin IV gets to therapeutic levels - it is often too high or too ...
Do you recommend automatically starting CRRT anticoagulation when initiating CRRT if there are no medical contraindications to anticoagulation?
Great question. My practice is that we don't. However, I wonder if we should. In any case, it is not unreasonable not to give it at the beginning and start it if the patient clots daily or more often. I think bleeding episodes tend to be very dramatic at times and result in clouding our judgement a ...
Are there instances when you recommend initiation of dialysis in patients with advanced chronic kidney disease who are scheduled for a major surgery but do not currently have any indications for renal replacement therapy?
There is this very annoying (annoying because I don't want to believe it) literature regarding CV surgery patients with CKD stages 4-5, but not on RRT, doing better post-op if dialyzed pre-op. It rarely rears its ugly head. Maybe there is something there despite my denial, or better yet my skepticis...
Do you avoid sodium zirconium cyclosilicate use in your patients with ESKD and hyperkalemia who also have peripheral edema?
I don't. The extra salt intake is a problem but so is the hyperkalemia. In general, I am conservative in giving potassium binders in hemodialysis patients because of the risk of polypharmacy.
How would you approach the workup and management of isolated inflammatory subglottic stenosis in a young previously healthy patient that is steroid responsive with a completely negative serologic autoimmune workup?
This is a relatively unusual situation in that idiopathic subglottic stenosis is typically not managed with systemic immunosuppression. The typical therapies are endoscopic and include dilatation (+/- intralesional corticosteroids), endoscopic resection, and cricotracheal resection. A recent large t...