Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you consider prophylactic antifungal treatment prior to immunosuppressive therapies in a patient with previously treated pulmonary coccidiomycosis and residual parenchymal changes?
If the pulmonary coccidiomycosis was treated in the past, I would not necessarily prescribe prophylaxis, but that also depends on the meaning of "residual parenchymal changes.” If you’re referring to post-inflammatory fibrotic changes, then prophylaxis likely is unnecessary. If you’re referring to c...
Would you use sumatriptan in a patient with a history of cerebral aneurysm rupture?
Yes. There is no evidence that the use of triptan in patients with an unruptured cerebral aneurysm, or in those who have a history of ruptured aneurysm that have been coiled or clipped, increases the risk of serious adverse events. I would not use them in the setting of acute subarachnoid hemorrhage...
When do you consider the use of steroids in the management of acute exacerbations in patients with cystic fibrosis?
Steroids have been shown to improve FEV1 and decrease hospitalizations when used as a maintenance treatment regimen in Cystic fibrosis patients. But due to the long-term adverse effects, steroids are recommended for daily use (Mogayzel et al., PMID 23540878).Small Pilot projects showed no statistica...
Do you routinely recommend suppressive antibiotic therapy for patients with spinal hardware infections who have undergone surgical debridement with retention of hardware?
Executive Summary: "State-of-the-Art Review: Diagnosis and Management of Spinal Implant Infections" was published in Clinical Infectious Diseases, December 15, 2024 issue, by Tai and colleagues from the University of Minnesota, Mayo Clinic, Hospital for Special Surgery (New York) and the University ...
Would you consider the use of an anabolic agent to promote fracture healing?
While there are no drugs FDA that are approved to enhance fracture healing, there is considerable literature and experience using the PTH-based anabolic drugs to attempt to heal a fracture. They are sometimes used in the setting of delayed union or non-union. They have been used in elite athletes to...
How do you approach a patient with atrial fibrillation on apixaban who has a new cardioembolic stroke?
Assuming that the apixaban dose was 5 mg bid, I would switch to warfarin and aim for INR 2.5-3.5.
What is your approach to treatment of patients with fulminant C difficile infection who required ileostomy creation or colectomy?
Great question. If the entire colon has been removed, I do not see a role for oral vancomycin.
Would you stop an ACE inhibitor/ARB or instead initiate a potassium binder to manage hyperkalemia in a patient with proteinuric CKD stage 5 who is on an ACEi/ARB?
This depends on where in CKD 5 the patient is, to some extent. Would also make sure to modify diet if possible and make sure on an appropriate dose of a loop diuretic. If very close to starting dialysis or getting a txp, I might reduce dose or stop, especially if a K-binder is expensive for the pati...
For patients with spinal hardware infections, in what circumstances do you recommend 12 weeks over 6 weeks of antimicrobial therapy?
Extrapolating from PJI data, I tend to treat longer, but not always IV if there is an oral option after initial IV therapy. A big blurry line is when do oral antibiotics stop being for treatment and start being suppressive? Anyone I'm considering for long term suppressive antibiotics, really gets a ...
Do you recommend combined baseline cortisol and DHEA-S testing to improve the efficiency and accuracy of adrenal insufficiency diagnosis?
Yes, especially in the absence of recent glucocorticoid exposure, which can lower DHEAS levels and make it less helpful. Han et al., PMID 39657727 recently published a comprehensive manuscript on this topic.