Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel patients with elevated factor VIII levels for their thrombosis risk?
I don't check the factor VIII level as part of a thrombosis workup because the result rarely if ever affects my management of these patients. I would explain to the patient that factor VIII levels are a function of several variables, including age, vascular health (and hence blood pressure, smoking,...
What protective post-op measures do you recommend for a patient with scleroderma and a history of ILD, PH, Raynaud’s and digital ischemia undergoing cardiothoracic surgery?
Appropriate post-operative care in patients with scleroderma is very important. In the context of the cardiopulmonary disease, volume management is very important with close monitoring in I/O's to optimize fluid status. In a patient with a history of digital ischemia, it is important to keep the pat...
What would be your recommendation for treatment of worsening lung disease in a patient with long-standing scleroderma after long-term mycophenolate therapy which is no longer an option due to side effect/intolerance?
Someone who has been on long-term Mycophenolate for interstitial lung disease and has had stabilization or improvement in their lung function and then is unable to tolerate the medication may be able to be switched to mycophenolic acid sodium (myfortic) which is often less toxic and better able to b...
Would you stop azathioprine in a patient with ANCA vasculitis who has been in long term remission on azathioprine, but has a new diagnosis of lung cancer requiring initiation of immunotherapy?
Data about the effect of immunosuppression on the efficacy of immune checkpoint inhibitors suggests that there is a negative of effect of being on immunosuppression at the time of ICI initiation on tumor response. So if the patient really has been clinically stable for a long time there are a few op...
Is there a kidney length for which you would no longer recommend attempting a kidney biopsy due to safety concerns and lack of diagnostic yield?
Yes. I definitely do not biopsy very small kidneys. Where you draw the line is the question. I think it is not only the size of the kidney but also the height of the patient. It may be OK to biopsy a patient with a 7.5 cm kidney who is 4 feet 8 but not OK to biopsy an 8 cm kidney in a patient who is...
Do progesterone only oral contraceptive pills affect cortisol binding globulin?
I do not recall any recent publications, but I am sure old studies have examined this question. Based on my clinical experience, there is no significant effect on total cortisol levels.
What 60 minute cortisol threshold value do you use for diagnosis of adrenal insufficiency after ACTH stimulation?
It depends on the assay. Different assays measure different things. Mass spectrometry is the most accurate available assay at present, and it measures ONLY cortisol. Immunoassays also detect other related compounds, and vary from assay to assay as to which ones. Discussed in PMID 25877990.
How would you approach post-operative VTE prophylaxis for renal transplant in patients with a prior history of provoked VTE?
I am not aware of published systematic reviews, risk models, or evidence-based guidelines for post-operative prophylaxis in renal transplant patients. Given both increased risk for VTE and bleeding, it is not surprising that there is a large variation in practice (for relatively recent survey on t...
When would you consider offering PVC ablation for otherwise healthy patients with preserved LV systolic function?
I would generally not offer an ablation for PVC burden alone but may consider further workup/counseling or even ablation if other factors are present. I would obtain a more detailed history to determine if the patient has symptoms/limitations that they did not initially express, which would lead me ...
How do you approach determining appropriateness for extubation in a patient with acute respiratory failure in the setting of known chronic neuromuscular disease?
This can be a very challenging situation in the ICU. I first discuss the options with the patient (if possible) and caregivers before considering extubation. I consider baseline/pre-illness data if available such as prior FVC or NIF/MIP, need for NIV, etc. Also, it is important to consider why they ...