Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are there instances when you do not recommend tunneled dialysis catheter exchange in patients on hemodialysis who are found to have bacteremia?
Generally, the answer is no. The only situation I would not recommend tunneled catheter exchange is if the patient has "run out" of catheter insertion sites and removal of the catheter poses the risk of not being able to place another tunneled catheter. That is also tempered by the organism causing ...
What specific markers or symptoms guide your decision to adjust or stop prophylactic calcium supplementation and calcitriol in managing postoperative hypoparathyroidism following thyroidectomy?
I will taper off calcitriol first when the PTH is measurable >15 and the phos is normal. These are very good predictors of normal function.
Is there any difference between colchicine 0.5mg vs 0.6 mg for high risk coronary artery disease?
Based on my subjective practice, no significant difference (have used both formulations). Any others have any different/similar experiences?
When do you recommend plasmapheresis/plasma exchange for management of severe hypertriglyceridemia?
Generally, I recommend plasmapheresis for severe hypertriglyceridemia when patients are admitted with acute pancreatitis who either do not respond to NPO (and/or insulin if they have hyperglycemia) or if they are critically ill with for example necrotizing pancreatitis. Triglyceride concentrations d...
Would you add an SGLT2 inhibitor to augment diuresis during a hospitalization in a patient with nephrotic syndrome, an eGFR above 30 mL/min/1.73m2, and refractory hypervolemia on an intravenous loop diuretic?
Establish true loop diuretic refractoriness (minimum frequency: BID, the max dose depends on CrCl). Add sequential diuretics. Metolazone or other thiazide-like diuretics, with without amiloride or spironolactone. (Latter diuretics are preferred if the patient is hypokalemic). Add 25% albumin if e...
Which factors favor extended dual antiplatelet therapy beyond one year in ACS patients with low bleeding risk?
Selecting an optimal duration of dual antiplatelet therapy (DAPT) for a given patient (whether "extended" or "short" in comparison to one year) must be personalized, with a calculus that considers an individual's competing risks of bleeding and thrombosis as a function of time.Accordingly, without b...
What is your approach for patients with recurrent nephrolithiasis who you have a strong suspicion for primary hyperoxaluria though genetic testing returns without any abnormalities?
As an adult nephrologist, most of my patients with oxalosis have enteric hyperoxaluria. I suggest you take a careful history, looking for inflammatory bowel disease, removal of small bowel or surgical rerouting of the intestines. If your patient is a child, I would explore the possibility of insuran...
How do you approach the treatment of indeterminate UIP on HRCT with grossly positive MPO antibody and no other features consistent with AAV?
We see these patients in our combined ILD/Rheumatology and would treat with immunosuppressive therapy. The indeterminant UIP is likely NSIP although UIP is not an uncommon pattern seen in these patients. ILD can be the presenting manifestation in ANCA-ILD in 14-85% of ANCA vasculitis patients depend...
What are reasonable next steps in the work-up of suspected ATTR amyloidosis if the PYP scan is equivocal, in light of the potential risks of endomyocardial biopsy?
Before addressing the next move after an equivocal PYP scan, some comments on PYP scan reporting are in order. Unfortunately, despite the relative simplicity of obtaining a high quality PYP scam, around 10 -20% of the ones that we see done at outside institutions (including teaching institutions) ar...
How do you manage incidentally identified pituitary lesions on brain imaging?
Pituitary lesions are among the most common incidentalomas seen on brain MRIs. Various studies cite numbers as high as 10- >30% for pituitary lesions found incidentally on brain imaging, with the higher incidence rates emerging in the era of high-resolution MRIs. In pediatric neurology/neuro-oncolog...