Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach restarting cDMARDS/bDMARDS in a patient with active RA after incidence of disseminated CNS VZV infection while on tofacitinib?
This is a complex problem for which any response clearly is not data-driven. Disseminated VZV is a profound illness and is linked to JAKi exposure. While the majority of VZV is 'mild' all complications are increased in this setting and dissemination is among the most serious and potentially fatal co...
Is it ever safe to use a biologic DMARD in a patient with RA who is on suppressive antibiotics due to a history of septic prosthetic arthritis?
I have used Orencia and HCQ as more immunomodulating with suppressive M/W/F antibiotics in a patient with UTI/Bactrim.
Can intra-abdominal pressure serve as a surrogate for pleural pressure to titrate PEEP in obese patients or those with intra-abdominal hypertension?
No. Duomarco and Rimini in 1947 clearly established the presence of regional abdominal pressures.
Would you accept the diagnosis of SLE on the basis of an AVISE CTD panel where the results just showed a positive EC4d or BC4d, positive ANA>1/80 + one clinical criteria such as multiple tender joints but did otherwise not fulfill criteria for SLE?
The answer is "Yes and No."@Dr. First Last: I am so glad you asked this question. I once observed a speaker give incorrect information on this topic with an answer of "yes."The quick answer, is that the AVISE Lupus Test (which uses EC4d and BC4d) result does NOT give a "yes" or "no" answer for someo...
When do you restart antiplatelet therapy in patients with hemorrhagic conversion of stroke?
This is a great question and not an uncommon clinical encounter for stroke neurologists. Indeed there is no one right answer. First, you may want to make sure that the observed ICH is true transformation of an ischemic lesion. Second, the degree of hemorrhagic transformation matters, I totally agree...
Would you change treatment approach for rectal cancer with an associated intussusception?
If the patient has obstruction, I probably would favor surgery first. If not, then I'd treat it as usual. It's a judgment call though.
What features on CTA/MRA are most helpful for differentiating large vessel vasculitis from atherosclerosis?
While calcified plaque is not typically mistaken for large vessel vasculitis, distinguishing non-calcified atherosclerotic lesions from large vessel vasculitis is challenging. An experienced vascular radiologist is an invaluable resource in such situations if available. The first step is to assess ...
Would you recommend transition to hemodialysis for a patient with calciphylaxis, hyperphosphatemia, and ESKD on peritoneal dialysis?
Changing from PD to HD is a tough decision but I would do it for calcemic uremic arteriopathy CUA (calciphylaxis) for two reasons, increase clearance and guarantee IV delivery of sodium thiosulfate (STS). Peritoneal STS has been describedMataic & Bastani, PMID 16771254But I think CUA is life-threate...
Below what platelet count would you avoid using an AV fistula in a patient with ESKD and thrombocytopenia?
Great question & the answer is likely debatable based on personal experience. Review of some case reports show no evidence of prolonged bleeding after AVF cannulation with platelet counts as low as 37,000 (1). Platelet counts can drop by 5- 15% with initiation of HD normally. They fall during the fi...
Would you recommend avoiding PICC line placement in a kidney transplant patient with an estimated GFR of more than 45 ml/min/1.73m2 and no functional AV access?
Great question and of course there is no data to guide decision-making in this scenario. Anecdotally, I would assess the patient as a whole, not just limited to current GFR though that is a great starting point. What is their age and co-morbidities - is this a younger /middle-aged/older patient, is ...