Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
Are there instances when you prefer serum creatinine over cystatin C when estimating GFR in a patient with CKD?
Overall serum cystatin C correlates better with measured GFR than does serum creatinine. The main block to more widespread use of cystatin C is its cost. I personally have not had an experience where the serum creatinine has been a better measure of GFR as opposed to serum cystatin C but there is da...
Do you recommend giving IV albumin with furosemide to augment diuresis in a patient with hypoalbuminemia and volume overload?
I'm a fan of IV albumin in patients with edema and hypoalbuminemia <3g/dL. It stabilizes intravascular volume and may blunt the rise in serum creatinine that can occur with diuresis. It may lead to a decrease in serum creatinine in some patients, especially those with liver disease and impending hep...
What is your approach to progressive calvarial hyperostosis found in an elderly adult not caused by Pagets, acromegaly or hypercalcemia?
Does your patient have meningioma? Is the osteosclerosis generalized or localized? Localized osteosclerosis can arise from tumors (either benign or malignant) that secrete osteogenic proteins. I have had such a patient, with the unresectable meningioma secreting endothelin. Endothelin is also secret...
Would you start any treatment for radiation pneumonitis if there is a large area of consolidation in the irradiated lung field but the patient is asymptomatic?
If the timeline matches then for radio graphic only pneumonitis, I would favor observation with a repeat scan in a few months.
Is there a role for nintedanib in the management of patients with radiation-induced pulmonary fibrosis?
There is no phase III evidence I am aware of on the benefits of nintedanib in the prevention of radiation-induced pulmonary fibrosis so it is not a drug I use. There are a few case reports and some pre-clinical studies suggesting an effect. There is a small (34 patients) randomized phase II study th...
At what point in GCA management do you typically introduce tocilizumab?
I typically introduce tocilizumab as first line therapy in combination with prednisone in patients who do not have a contraindication. The GIACTA trial demonstrated the superiority of TCZ+prednisone x 6 mos over prednisone alone x 6 or 12 months with numerically fewer serious adverse events. Given t...
Do patients with an elevated IGF-1 level and features of acromegaly need to have confirmatory growth hormone suppression testing with OGTT?
OGTT is not always needed. In the presence of clinical features of acromegaly, a frankly elevated IGF-1, and a pituitary adenoma visible by MRI glucose suppression test is not necessary.
Do you rule out active urinary tract infections prior to performing a kidney biopsy?
The 2 infectious reasons to avoid a renal biopsy are- active kidney infection and active skin infection at the site of the biopsy (Luciano & Moeckel, PMID 30661724).Perinephric hematoma is common after a kidney biopsy and there is a report in the literature where this has gotten infected in the pres...
When would you consider utilizing bone scintigraphy in the assessment of inflammatory arthritis?
When it's a case of negative RA disease or when considering a neoplastic, gammopathy with myeloma...