Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How would you approach the workup and management of a young patient with recurrent biannual non-scarring oral ulcers and new onset neurologic symptoms with associated CNS white matter lesions concerning for Behcet’s?
This is a challenging case. It should be noted that oral ulcers in Behcet's typically occur more than twice per year (by ISG criteria should occur at least 3x per year) and without other symptoms of BD it can be very challenging to make a probable diagnosis of BD in this scenario. A careful history ...
Are there patients with granulomatosis with polyangiitis on maintenance rituximab therapy for whom you do not co-administer glucocorticoid therapy?
I think this is a great question. @Dr. First Last et al (NCT01933724) have conducted a study to answer that question (conveniently called TAPIR). In their analysis that was presented 1 week ago at the International Vasculitis Workshop, they found that patients on low-dose prednisone along with other...
Do you extend the duration of maintenance therapy past 24 months for patients with ANCA glomerulonephritis who have multiple organ involvement?
The duration of maintenance therapy in patients with AAV depends on many factors and should be individualized. Some factors that are associated with a higher risk of relapse include PR3 positivity, seroconversion from negative to positive, ENT disease, use of a tailored approach to RTX dosing, and u...
How do you risk stratify patients with different WHO groups of pulmonary hypertension prior to non-cardiac surgeries?
First, I would direct the audience to recent AHA guidelines on the perioperative management of PH in non-cardiac surgery. Rajagopal et al., PMID 36924225In general, the severity of pulmonary hypertension and relevant comorbidities are likely more important than the WHO group. In patients with CTEPH,...
How would you approach secondary stroke prevention in an adult with Hemoglobin SC disease?
Stroke is less common in HbSC disease than it is in HbS homozygotes (Ohene-Frempong et al., PMID 9414296). Thus, there are no studies focused on primary or secondary stroke prevention in HbSC disease. Recent guidelines for stroke management were “silent” on stroke in HbSC disease (DeBaun et al., PMI...
In what situations would you consider ESAs in hospitalized patients with severe anemia for indications other than CKD or myelosuppressive chemotherapy (e.g., ACD, hemorrhage)?
In deciding on the risk-benefit of ESAs in patients with severe anemia due to bleeding and/or inflammatory disease, there are two considerations. The first is the severity of the anemia and consequently, the time to initial response. Using the standard dose of ESAs, it may take 8 to 12 weeks to achi...
What is your approach for steroid dosing for patients with ANCA vasculitis on induction treatment with rituximab, avacopan, and glucocorticoid therapy?
I do not personally have a one-size-fits-all approach. Remember that ADVOCATE had a screening window of up to 2 weeks where many patients got steroids before they were randomized. At the time of randomization, patients had to be on less than 20mg of prednisone which was tapered over 4 weeks.In addit...
How do you treat CTD-associated organizing pneumonia?
I agree with what Dr. @Dr. First Last has said. To answer your question specifically, organizing pneumonia is slightly different to other forms of ILD. OP tend to have much better response to steroids in general. As with most other ILD patterns, CTD-OP has slightly worse prognosis than COP. So I am ...
How do you counsel patients with ALS on the benefits of enteral nutrition?
I agree with Drs. @Dr. First Last and @Dr. First Last but what I find frequently is that patients are reluctant to have PEG because of a number of psychological factors; fear of the surgery, fear of having a tube, fear of disease progression, fear that it will keep them alive indefinitely as in the ...
What is your approach to GDMT uptitration (particularly dosing for ARBs/ARNIs/MRA) if there is further evidence of renal dysfunction, especially in situations with worsening AKI on CKD?
Titration of RAAS inhibitors in the setting of AKI on CKD is challenging. First, look at the patient: if they have an increase in Cr after an increase in the RAAS inhibitor but no/stable HF symptoms and appear euvolemic on examination, then I will decrease diuretic therapy and see if the Cr improves...