Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to management of pulmonary fibrosis in patients with a history of microscopic polyangiitis who do not have other active organ involvement?
ILD is an important organ manifestation in AAV, typically seen in patients with MPO-ANCA where ~20% of patients have ILD which often precedes the diagnosis of AAV. The most common radiographic pattern is UIP. ILD has been associated with a higher risk of mortality in AAV in multiple series including...
For patients with candida species osteomyelitis who have undergone extensive surgical debridement, do you routinely still recommend 6-12 months of antifungal therapy or opt for a shorter duration?
After removal of hardware, if present, and debridement of infected bone, my practice is to treat Candida osteomyelitis with an intravenous echinocandin for two weeks followed an oral azole, to which the fungus is susceptible, for at least six months. If full debridement is not possible, such as vert...
What is the utility of MRI for identifying disease activity in myositis patients when physical exam and labs are inconclusive?
Agree with @Dr. First Last, however, I want to caution about sensitivity and specificity of muscle MRI for a particular situation you are suggesting i.e., to evaluate if patient has active or inactive disease, has not been studied or proven. The muscle MRI, in general, has good sensitivity and speci...
Do you ever use ocular ultrasound in evaluation of papilledema?
As a neuro-ophthalmologist, I never use ultrasound to make a diagnosis of papilledema. I do use it to reveal optic nerve head drusen that also cause axoplasmic flow stasis and can mimic papilledema. A high quality set of fundus photos is very useful for determining the presence of optic disc edema.
What infections should we rule out in patients who develop diarrhea on immunotherapy?
Immunotherapy is known to be associated with immune-mediated diarrhea and colitis (IMDC). However, it remains unclear whether cancer patients undergoing immunotherapy are at a heightened risk for Clostridioides difficile colitis infection (CDI). A retrospective study focusing on patients treated wit...
Do you recommend CT perfusion in patients presenting with symptoms of acute stroke before 6 hours?
Routine CTP is not required in the <6 hours according to the AHA/ASA guidelines. The TENSION large core data would also support not requiring CTP in the early window.In the >6-24 hour period, the MR CLEAN-LATE trial, which was based on patients with CTA collaterals selection, showed favorable outcom...
When do you consider stenting in patients with recurrent stroke with ICAD?
I agree with the answers mentioned above. Additionally, I ensure that the patient has made diligent efforts to address modifiable risk factors, with smoking cessation being of utmost importance, along with medication compliance. The specific area of stent placement and the type of stent used may var...
What is your approach to treatment in a patient with radiographic UIP but pathologic evidence of both fibrotic NSIP and UIP?
Depends on the underlying etiology and progression. I will most likely use antifibrotics, particularly for IPF or progressive fibrosis, but include immune suppression for autoimmune-related ILD.
Should methotrexate be stopped prior to radiation therapy if a patient has rheumatoid arthritis?
I have not stopped as dose of MTX for RA is low (7.5 mg) and there is data of CMF with RT for breast cancer with higher dose of MTX showing no significant increase in morbidity.
What antibiotics would you use for empiric treatment of a brain abscess in patients allergic to penicillin, metronidazole, and vancomycin?
Linezolid/Bactrim/Ceftaroline?