Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Why do we not typically see features of rhabdomyolysis or acute kidney injury with idiopathic inflammatory myopathies?
Because rhabdomyolysis leading to AKI means acute massive necrosis of a large number of muscle fibers with resulting release of myoglobin In blood and precipitation of myoglobin in renal tubules, leading to tubular necrosis. This acute extensive myonecrosis typically does not occur with IIMs, with t...
Would you consider using DOACs in a young patient with SLE and Libman-Sacks endocarditis, who is negative for APS?
In this scenario, our patient with lupus is young and does not have features of APS. Nevertheless, any patient with Libman Sacks endocarditis carries a heightened risk for embolization. Regarding anticoagulation, the literature on this subject is anecdotal and conflicting with some authors recommend...
What are the alternatives to anticoagulation in an individual with an atrial thrombus and absolute contraindications to anticoagulation?
This is not an easily answered question in this sort of a forum. This clinical situation requires multidisciplinary input and individualized approach. Factors to consider include but not limited to, 1) estimated risk of systemic arterial embolism (note, current tools/calculators provide the annual r...
Is there a role for antifibrotic therapy in post COVID-19 pulmonary fibrosis?
As you may know from working with these patients in the acute and post-infection (PASC - post-acute sequelae of COVID-19) settings, there is a spectrum of lung injuries that can ensue after infection with SARS-CoV-2. This spectrum is composed of mild GGOs to organizing pneumonia to fibrosis (or, fre...
Do you routinely continue airway clearance therapies in the setting of mild to moderate hemoptysis in a patient with CF?
I typically hold it temporarily until hemoptysis resolves or decreases.
Is there a role for the use of inhaled corticosteroids in patients with pulmonary sarcoidosis who have stage II or III disease with abnormal lung function but only mild respiratory symptoms?
There are several older studies that have tried to answer this question.Du Bois et al., PMID 10445610: 44 stage II or III patients randomized to placebo or fluticasone 2mg/day, showed no statistically significant difference in symptom scores, PEFR, or FEV1 over 6 months (although trend towards impro...
How do you treat patients with sarcoid who have persistent symptoms after an initial 6 week course of corticosteroids?
The answer to this question depends on what organ(s) you are treating and how severe the manifestation(s) is/are because you must balance the risk of the treatment itself, and the risk of flare with an aggressive steroid taper. 6 weeks of steroids is not appropriate for cardiac sarcoidosis that over...
Do you consider EBUS TBNA in the diagnostic evaluation of patients with mediastinal lymphadenopathy with concern for lymphoma?
Yes, very commonly. The traditional thought is that histological architecture is needed to diagnose lymphoma. However, with flow-cytometry, we can diagnose all types of NHL. We always try to get a lot of aspirations (more than 7-10 passes) from the lymph nodes or mediastinal masses to prepare a good...
What is your approach to the monitoring and management of a never-smoker with respiratory symptoms and a nonspecific ventilatory pattern on pulmonary function testing?
In the RETHINC trial, inhaled dual bronchodilator therapy did not decrease respiratory symptoms in symptomatic tobacco-exposed people. We still do not know how best to address symptomatic people with PRISm or those with or without a smoking history and respiratory symptoms without obstruction on spi...
Do you stop PPI when starting patients on immunotherapy?
Proton pump inhibitors (PPI) are commonly used in cancer patients and may affect the gut microbiome by altering gut pH. The gut microbiome plays a critical role in modulating the therapeutic effects of immune checkpoint inhibitors. PPI use in patients treated with immunotherapy has been associated w...