Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?
I've personally seen as long as 30+ days but usually less.
What is the management strategy for patients who develop AKI and nephrotic range proteinuria secondary to biopsy proven FSGS during immune checkpoint inhibitor therapy?
For glomerulonephritis induced by ICI would recommend rituximab 1 gram for a total dose of 2 doses 2 weeks apart. Based on limited case reports there has been a good response to rituximab with maintained remission of glomerulonephritis and the ability to continue on ICI without relapse. Please refer...
Would you transition from IV to oral antibiotics in a solid organ transplant recipient with uncomplicated gram-negative bacteremia?
Yes, I would in the right circumstances. The referenced article by Nussbaum et al., PMID 38195100 provides reasonable evidence that this is a valid approach. Particularly, if the patient's net-state-of-immunosuppression is not terribly high and the organism is susceptible to highly bioavailable oral...
Do you still consider hepatorenal syndrome in patients with renal impairment and liver disease who are found to have rare muddy brown casts on urine microscopy?
I personally do. While the traditional teaching is to try to differentiate ATN versus pre-renal versus HRS using the urine sodium, history, and urine microscopy. While sometimes one diagnosis is compelling, often the clinical picture is not clear cut, and at times there is a component of ATN on some...
Are there instances when you recommend performing a kidney biopsy in patients with presumed acute interstitial nephritis who are already on steroids and have improving renal function?
The decision to perform renal biopsy in a patient with presumed allergic interstitial nephritis on steroids, who is demonstrating improvement depends on the magnitude and rate of improvement. In a patient whose magnitude and rate of improvement, I suggest that the prior acute kidney injury baseline ...
What is your intraprocedural approach to reducing time to reperfusion in STEMI cases: opting for culprit lesion PCI first then complete angiography, or complete angiography followed by culprit lesion PCI?
Great inquiry. A lot of it depends on the clinical acuity of the presentation as well as systems-based processes as well. If the patient is more unstable with hypotension/bradycardia or other unstable vital parameters, and the EKG is clearly pointing to a certain territory, then in order to avoid de...
Do you have a preference between Quantiferon Gold and T-spot TB for screening in patients starting immunosuppressive agents?
TSpot testing has better performance than Quantiferon Gold in patients with low lymphocyte levels, and/or on glucocorticoids (especially moderate to high doses). This is partially related to the way the essay is performed, and as such the Tspot is much less likely to result in an indeterminate or fa...
What is your approach to managing patients with new laboratory evidence of hypopituitarism (e.g. very low plasma ACTH level and low morning serum cortisol) and a remote history of trans-sphenoidal surgery for NFPA?
It is sufficient to start corticosteroids with mineralocorticoids in such patients.
What is your initial treatment of choice in patients with RA and associated interstitial lung disease?
Because of the nature of the disease and to avoid unnecessary ILD treatment, it would not be appropriate to provide the 'direct answer' first. But the direct answer will appear in bold at the bottom. Of note, there is little data on therapeutics in RA-ILD. This is an important question because it hi...
What are best practices in management of severe acute infusion reaction from infliximab?
Severe infusion reactions to infliximab are not typically IgE-mediated. The presumption is that it is ‘anaphylactoid’ due to IgG antibodies directed against the mouse chimeric proteins in the molecule. Stopping the infusion is essential (at least temporarily) and administering antihistamines such as...