Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you typically adjust or hold immunosuppression in a well-controlled RA patient who is being treated for Mycobacterium avium-intracellulare (MAI)?
It depends on the RA activity and shared decision-making with the patient. A lot of these patients are at risk of MAI infection due to their underlying immunosuppression and on higher levels of immunosuppression because they have more severe rheumatoid disease process. Very often it is difficult for...
Are CGRP antagonists effective at aborting intractable headaches in hospitalized patients when traditional “migraine cocktails” have failed?
The time has come for us to limit ourselves in our treatment of migraine patients to migraine-specific medications. These are the triptans and gepants for abortive treatment and the CGRP antibodies and gepants for preventive treatment. The "migraine cocktails" that we employ in emergency room and ho...
Would you consider reducing the dialysate sodium concentration to 135 meq/L as a strategy to decrease interdialytic weight gain in a hypervolemic ESKD patient?
Yes. It is worth a try. I don't expect miracles though. It may make a minor difference. The best option remains longer and more frequent dialysis if possible and agreeable with the patient which is often not the case.
How do you manage hyperalgesia in patients with sickle cell disease?
In addition to the obvious, such as PCA narcotics, Lyrica/Neurontin, and Toradol, I have success with IV Tylenol, Zyprexa, po L-Arginine (Morris et al., PMID 23645695) as well as Dexmedetomidine (Precedex), steroids (NEJM: Griffin et al., PMID 8107739) and acupuncture [Johnson et al., Alternative an...
How do you distinguish between primary and tertiary hyperparathyroidism in a patient with ESRD?
Almost all patients with hypercalcemia, hyperparathyroidism, and ESRD are going to have tertiary HPTH and not primary. Imaging will show diffuse hyperplasia and multiple nodules in tertiary and in the rare case of primary would expect to see a solitary nodule without hyperplasia of the other glands....
What are the clinical indications and major limitations of lipoprotein apheresis?
LDL apheresis is a procedure that selectively removes apo B-containing lipoproteins (so primarily LDL particles) from the circulation. Very simply - venous blood is withdrawn via IV, plasma separated by the machine (liposorber, FDA approved in the US), passed through a column which binds the apo B c...
What is the approach to use of ACE inhibitors for suspected scleroderma renal crisis in patients with only mildly elevated BP and renal artery stenosis?
I recommend using a short-acting ACEi, like captopril, to treat scleroderma renal crisis. You can start at 6.25mg TID and rapidly titrate up the dose to achieve blood pressure goals. The presence of renal artery stenosis (RAS) would not dissuade me from using an ACEi, if there is evidence of thrombo...
How do you manage patients with systemic sclerosis and chronic thrombotic microangiopathy on renal biopsy, but no other evidence of scleroderma renal crisis?
Very good question. Disclaimer 1st - I am not a nephrologist or nephropathologist so this really requires putting many heads together! Thrombotic microangiopathies (TMA) are clinical syndromes defined by the presence of hemolytic anemia, thrombocytopenia, and organ damage from micro thrombosis in ca...
Would you recommend a TIPS procedure in the management of hepatorenal syndrome for a patient with no history of hepatic encephalopathy?
In the right patient, yes. TIPS will help with ascites and likely with renal function. I believe it is underused.
What are the reasons for SLE specific labs to turn negative?
I agree and appreciate the answers by Dr @Dr. First Last and Dr @Dr. First Last. My answer may be stating the obvious, but I think it is important to mention that lupus is not infrequently over-diagnosed and overtreated. Serologies are sometimes over-interpreted with low-titer antibodies labeled as ...