Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
In which clinical scenarios do you use prolonged intermittent renal replacement therapy (PIRRT)?
I have not been using PIRRT. We talked about it at the height of COVID when we thought we were going to run out of CVVH solutions. However it never needed to be instituted. Other than that scenario, I think we can tweak the settings of the CVVH machine enough to provide aggressive renal replacement ...
How would you approach a patient with end stage kidney disease on peritoneal dialysis who has an adequate Kt/V but persistent azotemia?
This question could serve as the springboard for a very lengthy discussion/ debate regarding PD "adequacy"- a term that ought to be outlawed! That said, I will try to be brief. First off, it must be recognized that Kt/V (by default meaning that for urea) is a very poor measure of the quality of dial...
What is your approach to evaluation in patients who present with erythromelalgia?
Erythromelalgia is a tough condition to treat. I usually break it down into diagnostic workup and treatment as follows: Diagnostic workup: I usually just get a CBC yearly to look for myeloproliferative disorders. Treatment: I have not had a lot of luck with topicals being too effective, so I usuall...
Would you consider switching choice of P2Y12 inhibitor for patients with ISR (non-ACS presentation), with acceptable bleeding risk?
There is no need to change P2Y12 inhibitor in case of ISR without ACS. There are no studies that suggest such approach is indicated or can be helpful. Also, patients are taking their current P2Y12 inhibitor for a while and they are used to the medications. Changing the medication can raise cost with...
When do you begin antifibrotic therapy for a patient with newly diagnosed ILD that is not IPF?
The evidence behind starting anti-fibrotic therapy for non-IPF ILD is largely based on the results of the INBUILD trial where patients who have non-IPF ILD who demonstrate progression (based on at least a 10% decline in FVC or a 5% decline in FVC with worsening symptoms or radiologic progression) ha...
If you have clinical suspicion for a paraneoplastic process (e.g. dermatomyositis or pemphigus), what work-up do you pursue?
This continues to be a topic of high interest. The first-ever evidence and consensus-based recommendations were recently drafted by an expert international committee under the auspices of the International Myositis Assessment and Clinical Studies (IMACS) group (in preparation). These recommendations...
Do you recommend prophylactic post-operative use of an intravenous calcium infusion for patients with ESKD who undergo subtotal parathyroidectomy for secondary hyperparathyroidism?
Ionized calcium concentration should be monitored closely post-operatively for hungry bone syndrome. Intravenous calcium infusion is indicated if there is a rapid and progressive decrease in the serum ionized calcium level.
What factors do you consider while selecting high risk patients for prophylactic NIV after planned extubation?
I use prophylactic NIV in severe Cardiomyopathy/CHF, severe COPD, and Obesity hypoventilation.
When do you consider the use of corticosteroids in patients diagnosed with EVALI?
If they have ground glass opacities on CT which is considered to be secondary to EVALI.
Would you consider anticoagulation for a young patient with a recent embolic stroke and newly diagnosed global cardiac hypokinesis with ejection fraction of less than 25%?
Yes, I would consider anticoagulation but the evidence is indirect. There is reasonable data in persons with heart failure with reduced ejection fraction that ischemic stroke is reduced with anticoagulation compared to antiplatelet therapy alone. But essentially all large RCTs are limited in that th...