Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to managing hypokalemia in patients with Bartter syndrome who are on high doses of potassium chloride but cannot tolerate amiloride or ACEi/ARBs due to low blood pressures?
Since prostaglandin level is typically high in patients with Bartter syndrome, NSAIDS can be tried to treat hypokalemia in these patients who cannot tolerate amiloride or ACEi/ARB due to low blood pressure. However, close monitoring of renal function is required if NSAIDS were to be given in these p...
Do you use acetazolamide to aid diuresis in patients with acute on chronic respiratory acidosis with significantly elevated serum bicarbonate levels?
Yes, acetazolamide can be used in aiding diuresis in patients with chronic respiratory acidosis where the metabolic compensation results in an alkalemic pH which then sets up a vicious cycle of increasing CO2 as a compensation for the metabolic alkalosis. Use of acetazolamide results in a metabolic ...
For hypogammaglobulinemia as a complication of successful treatment, do you empirically start prophylaxis with either 400 mg/kg monthly for IVIG or 100 mg/kg weekly for subcutaneous immune globulin?
Most of the data to support IVIG for hypogam comes from CLL literature. Data in those post-transplant and post-CAR T are limited. IVIG has a reputation of being a bit of a panacea, but I challenge that notion. We investigated the implementation of an IVIG stewardship plan to limit IVIG usage just fo...
Do you continue methotrexate in patients with inflammatory arthritis who develop non-melanomatous skin cancer while on therapy?
Data on methotrexate use and the increased risk of non-melanomatous skin cancers has been conflicting, suggesting an increased risk or a neutral risk. A recent case-control study published in the British Journal of Cancer (Polesie et al., PMID 36739322) did suggest an increased risk of both squamous...
Can transudative pleural effusions lead to trapped lung?
Yes. I’ve seen it many times especially in patients with longstanding CHF and/or CKD. With a persistent effusion of any type, the pleura can respond by forming a peel resulting in a non expanding lung.
When is the best time to consider left atrial appendage closure for secondary stroke prevention in patients with atrial fibrillation?
There is equipoise about the timing of left atrial appendage closure following ischemic stroke. Due to the need to temporarily treat a patient with either dual antiplatelet or anticoagulation therapy, it is reasonable to wait until after the acute stroke period has passed to allow for healing of inf...
Do you use absolute random cortisol levels or delta cortisol levels after ACTH stimulation to diagnose adrenal insufficiency in the critically ill?
As reviewed recently by Dr. Teblick et al., PMID 35358303, this is still a controversial and complex issue. Based on many studies, it would be preferable to avoid ACTH stimulation unless there is rapid availability of free cortisol. Random total cortisol is probably the better alternative.
What additional studies would you obtain for a patient with end stage kidney disease on hemodialysis who has persistent hypercalcemia and low PTH?
No studies or measures until I got the patient off Vit D, sensipar, and possibly Ca-based binders, and watched for a couple of months to see if PTH came up and hypercalcemia resolved. This is typical adynamic bone disease until proven otherwise.
What is your approach to management of radiation-induced bullous pemphigoid?
Bullous Pemphigoid (BP) is a pruritic autoimmune blistering disease characterized by tense bullae that is rarely caused by radiotherapy. There have been >30 reports in the literature related to RT with most being localized to the radiated location, with rare reports of BP at non-irradiated sites or ...
How do you interpret negative HMGCR antibody test results in a patient with necrotizing myopathy who has already been on treatment with steroids and whose CK has normalized?
HMGCR antibodies tend to remain present over time, even during periods of disease remission. Only recently have we began observing negative results in patients undergoing long-term treatment. Therefore, considering the patient received steroids for only a brief period, it's reasonable to suspect tha...