Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there a role for SGLT-2 inhibitors in the treatment of chronic hypomagnesemia?
A meta-analysis of 18 randomized controlled trials showed that the use of SGLT2 inhibitors can result in a significant increase in the serum magnesium level. These trials, however, were not specifically designed to assess the effect of SGLT2 inhibitors on the serum magnesium level. Studies have show...
How do you manage a DOAC if interested in testing for lupus anticoagulant?
Testing for anti-phospholipid antibodies encompasses two broad categories of testing. One is an ELISA based (aka solid phase) set of tests that include anti-cardiolipin and anti-beta 2 glycoprotein I antibodies. ELISA assay are not affected by DOACs. For the second lupus anticoagulant (aka fluid pha...
What are the indications for anticoagulation in splenic infarctions?
A great reminder that splenic infarct relates to ARTERIAL thromboembolism and not to VENOUS VTE. Too often, I see massive, blind thrombophilia work-up for (incidentally) detected splenic infarcts.
How do you approach evaluation for underlying rheumatologic disease in patients with chronic asymptomatic thrombocytopenia?
APL testing as well as evaluation for SLE and Sjogrens with complement, urine, antibody testing, not just an ANA.
How do steroids and/or DMARDs affect biopsy results if a renal biopsy for suspected lupus nephritis is delayed?
In contrast to GCA/TA, where the Mayo clinic has published data that steroid treatment for as much as circa 2-4 weeks is unlikely to result in a false-negative biopsy, as long as accounts for the skip phenomenon and carefully examines multiple sections of the biopsy, I am unaware of similar informat...
For patients who have previously undergone MAZE ligation presenting with paroxysmal atrial fibrillation, how would you counsel them on the risk of stroke long-term when deciding whether or not to start or continue anticoagulation?
The decision to start or continue anticoagulation in patients with atrial fibrillation can be challenging, even after LAA closure. Specifically related to surgical closure of the LAA (excluding percutaneous LAAO, such as Watchman or Amulet), anticoagulation is still recommended indefinitely if suppo...
Are there instances when you use erythropoietin stimulating agents in patients with acute kidney injury requiring dialysis?
I cannot think of a reason to. ESA resistance is common in sick patients and I think you are wasting the drug. Please see reference: Aoun et al., PMID 35279078'Erythropoietin treatment had no impact on transfusions, renal recovery or mortality in acute kidney injury patients with anemia."
How do you dose gabapentin in patients with renal failure?
There are many algorithms available online about the renal dosing of gabapentin. However, it should be emphasized that the recommendations are not based on large patient studies; therefore, the efficacy of the reduced doses for neuropathic pain is not certain (Raouf et al., PMID 28184168).
Do you ever start a ketogenic diet in patients who present with status epilepticus admitted to the ICU?
A ketogenic diet can be considered in super-refractory status epilepticus. There are a handful of small studies and case series that are mostly pediatric, but also a few adult papers (Camões et al., PMID 35081248, Katz et al., PMID 33671485, and Cai et al., Acta Epileptologica 2022), which suggest t...
How would you approach management of a patient with a medium-to-large vessel vasculitis who developed perforation of the stomach and colon on steroids and cyclophosphamide?
The answer to this question is complex as will depend on the most likely option for the etiology of the perforation and the nature of the underlying vasculitis. If the perforation is felt to be because of vasculitic activity then the decision could be whether to continue the current therapy (not eno...