Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you recommend monitoring IgG level in patients with AAV receiving rituximab?
Yes! At the OSU Vasculitis clinic, we check IgG before every rituximab infusion. At a minimum, it must be done yearly to ensure no impending CVID or to change rituximab.
How do you manage immunosuppressive medications in patients who develop a pneumonia?
For most bacterial pneumonia in transplant patients, I prefer to avoid changing immunosuppressives and simply administer appropriate antibiotic therapy. This approach is effective and minimizes the risk of triggering acute rejection. For viral etiologies, I will often reduce or hold cell cycle inhi...
How would you approach peri-operative immunosuppressive management of a patient with Behcet's, currently controlled on azathioprine, who needs genital surgery?
It might be helpful to know what kind of genital surgery is planned and why. Here are a few general thoughts: There are little data to guide a unified approach outside of BD patients who need vascular surgery. Standard rules of thumb are to 1) reduce surgeries to a necessary minimum and 2) regard mo...
For an asymptomatic patient discovered during workup for elevated PT/PTT to have mild prothrombin deficiency, would you suggest any preoperative prophylaxis?
In someone with normal liver function otherwise, who was found on preoperative screening to have both mildly prolonged PT and PTT, AND the only abnormality found was a factor II (2, prothrombin) level >60%, I would not administer preoperative prophylaxis. However, I find the question confusing as it...
How should one approach an incidentally found T-cell gene arrangement?
When I see an incidental T-cell clonal rearrangement without any manifestation, my first question is how was this being measured? Many PCR-based methods have a difficult time distinguishing oligoclonal versus monoclonal T-cell populations. My favored test here is looking by flow cytometry at the T-c...
Is SVC syndrome a medical emergency?
It is usually not an emergency but rather a medical urgency and all effort should be made to get a tissue diagnosis before treatment. The goal of treatment could be curative or palliative based on the histology, stage of disease, and performance status of patient
Do you routinely use tumor lysis prophylaxis when starting chemotherapy for germ cell tumors?
THere is not reason to use tumor lysis prophylaxis. Hydration of course is required for the cisplatin. I am not aware of anyone using allopurinol or other TLS approaches
What techniques do you use to treat patients who weigh more than the treatment table limit?
In our institutional experience, this weighty question arises more often than we would prefer and most commonly for cervical cancer patients. If the patient is only nominally beyond the limit, it is important to consider that the weight limits are consequent to the tolerance parameters of the motors...
What is your next step in management for a patient with immunotherapy induced pneumonitis that does not improve on high dose steroids for 48 hours?
There is an excellent answer to this question from my colleague Dr. @Dr. First Last that can be found here. She provides an overview of the data as well as multiple references.
How would you manage palliation in a patient with postobstructive pneumonia caused by a mediastinal mass?
I'm guessing you're thinking of a lung cancer patient with hilar obstruction, lobar atelectasis, and 2nd pneumoia. These patients often get great palliation from RT. The primary challenge is finding the obstructing mass (which benefits from RT) and separating it from the infection (doesn't benefit)....