Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are you using NAC in lieu of hypertonic saline amidst the current shortage of hypertonic saline in patients with either CF or non-CF bronchiectasis?
The Mogayzel and colleagues guidelines for maintenance of lung health do not recommend for or against NAC in the treatment of CF Lung disease. In contrast, they do recommend the chronic use of HTS. Mogayzel Jr et al., PMID 23540878In CF and Non-CF bronchiectasis, my first choice is inhaled hypertoni...
With the approval of oral JAK inhibitors such as Upadacitinib for atopic dermatitis, how are you considering its safety profile in comparison to traditional immunosuppressants such as prednisone, methotrexate, azathioprine, and mycophenolate?
I agree with Dr. @Dr. First Last and would add the following: JAKi are actually generally safe if you look at the clinical trial data, especially compared to some of these less targeted immunosuppressants. However, when comparing to medications like dupilumab and talokinumab, the risk-benefit ratio ...
Would you give antithrombin concentrate for surgical VTE prophylaxis in case of congenital AT deficiency?
There is no role for routine antithrombin (AT) infusions. In selected situations, during high risk e.g. periods surgery or labor and delivery, etc when anticoagulants are interrupted, AT replenishment is reasonable.
How would you manage someone with antithrombin deficiency who has recurrent VTE on a DOAC?
I would consider Coumadin or an alternative NOAC. Repeat eval to make sure there is not a second gene defect. Also consider antithrombin III prophylaxis.
How do you interpret elevations in antiphospholipid antibodies that are lower than Sapporo criteria?
I would refer to the following article that provides the most up-to-date definitions (including the definitions for low-level antibodies) and risk stratification tools including APL-S and GAPSS that are developed for people with autoimmune conditions. The article also discusses the levels of evidenc...
When would you consider a workup for C. diff in a patient with diarrhea under-going concurrent chemoradiotherapy for rectal cancer?
Good question – and hard to pinpoint a strict answer. I think any time the diarrhea is out of proportion to expectation (i.e., very early in RT course), clinically significant (dehydration, etc), and not controlled or responding to anti-diarrheal medications, especially in the setting of C. diff ris...
What is your approach to workup for an underlying disorder in a patient with bilateral hip avascular necrosis?
The approach to assessing hip osteonecrosis is to address the potential causes: Is there a history of antecedent trauma? Is there a family history of osteonecrosis? Is there a history of significant alcohol use? Is there a history of recent corticosteroid use? Is there a history of pancreatitis? Is ...
Would you consider the use of dual antifibrotic therapy (nintedanib and pirfenidone together) for progressive fibrosing ILD?
Pirfenidone and Nintedanib have different antifibrotic mechanisms of action, and emerging data suggests that these complex molecules may possess previously unknown pleiotropic properties. It is unclear whether a synergistic effect might be realized from combination therapy with these agents, and ind...
Do you recommend genetic testing after a patient on clopidogrel has a stroke based on the results of the CHANCE-2 trial?
No, the data from CHANCE-2 (Wang et al., PMID 34708996) was based on a strictly Asian population and results need to be validated elsewhere for it to change practice.
What is the negative predictive value of a negative extended myositis panel in dermatomyositis patients?
The short answer is "not great, but it depends" since the more nuanced answer is contingent on: the constellation of myositis-specific antibodies (MSA) included on the panel, the nitty-gritty of how the commercial lab is checking the MSA included (this detail can change between vendors, or even ...