Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What are the next steps in the management of a patient admitted with an IPF exacerbation resistant to steroid therapy?
IPF exacerbation is associated with a poor prognosis, with an in-hospital mortality rate of up to 50% in one study (Song et al., PMID 20595144). As discussed earlier by Dr. @Dr. First Last, there are currently no established or evidence-based pharmacotherapies for managing IPF exacerbation. Aggressi...
What criteria do you use to determine when to start a steroid-sparing agent for hypersensitivity pneumonitis?
This is a very challenging question, acknowledging the difficulty in confidently establishing the diagnosis of HP, limited evidence in general to guide the treatment of HP, and recent small observational studies that conflict prior small observational studies. To attempt to answer, breaking down int...
Are there instances where you may transiently transition a perioperative ESKD on PD inpatient from peritoneal dialysis to hemodialysis if they are likely to receive a large volume of fluid?
Most peritoneal dialysis patients should be able to continue with PD while in the hospital. For patients with acute volume overload, hypertonic dextrose solutions can be used. However, there may be special circumstances where patients on peritoneal dialysis will need a temporary transition to hemodi...
Which fracture sites outside of the classical spine and hip are considered to be osteoporotic fractures even in the absence of a bone density diagnosis?
Any bone that sustains a fragility fracture can result from osteoporosis. The definition for fragility fracture is a broken bone that occurs after a low-energy trauma, such as a fall from standing height or less, or lifting something light. They are a type of pathologic fracture, which means they ha...
Is there a serum phosphorus level you would consider too low to safely perform hemodialysis?
I actually do. I have previously published reports of 2 patients who developed recurrent encephalopathy due to dialysis-induced hypophosphatemia. They were treated with adding phosphorus to the dialysis fluid and the episodes did not recur (Koganti & Sam, PMID 31940631). I definitely do not want the...
For patients with hypertension who have normal filling pressures following right cardiac catheterization, can hypertension still be attributed to volume overload?
I do not think of chronic hypertension as a disease of volume overload. Loop diuretics are indeed very poor antihypertensive agents. I agree that cardiac loading conditions are dynamic, but in a patient with normal filling pressures and hypertension, I would think of inappropriately increased periph...
Would you recommend initiation of cinacalcet in a patient with hypercalcemia and recurrent nephrolithiasis attributed to an atypical presentation of familial hypocalciuric hypercalcemia?
I would really like to know the level of the patient’s parathyroid hormone. If it is low, cinacalcet would probably not be helpful. Stephen B Erickson, MD
What is your approach to risk stratification of asymptomatic patients with pre-excitation syndrome?
When addressing pre-excitation on EKG, some good references include: ACC online expert analysis 2012 PACES/HRS expert consensus statement Editorial on the 2012 PACES guidelines about the challenges of being more aggressive In general, I agree with Dr. @Dr. First Last and the ACC expert analysis that...
What is your approach to the management of persistent hydropneumothorax due to a non expandable lung?
This depends on the clinical scenario and really, relating to patient factors. For instance, if a patient is young without many co-morbidities and the non-expandable lung is related to a 'benign' etiology (i.e. empyema that has resolved and is now a transudative effusion), then surgical consultation...
Based on findings of the INCREASE trial, are you routinely prescribing inhaled treprostinil to patients with group 3 pulmonary hypertension secondary to interstitial lung disease?
As a brief background, the INCREASE trial (Waxman et al., PMID 33440084) was a randomized trial in patients with pulmonary hypertension due to interstitial lung disease (PH-ILD) assessing the effect of inhaled treprostinil versus placebo on change in 6-minute walk distance at 16 weeks. The study enr...