Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Would you recommend discontinuing testosterone replacement in a male patient in his 60s with newly diagnosed favorable intermediate-risk prostate cancer who is declining surgery and will receive definitive radiation?
Historically, we (as a field) have viewed TRT as the opposite of ADT and therefore inherently problematic. I am not convinced this is logical. ADT has RCT evidence to support it, whereas withdrawing TRT has not been as cleanly studied. Let's say we stop TRT, and this drops their testosterone to 150 ...
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
How would you manage persistent Norovirus diarrheal infections in a kidney transplant patient that are not responding to a decrease in the patient’s maintenance immunosuppressive regimen?
This is a difficult situation and does not have a strong evidence based response. First, I would really make sure they are not on mycophenolate as this is really the main problem with chronic Norovirus for most patients. Next, I would see if there are any available clinical trials that the patient m...
When do you refer patients back to their PCP for the predominant management of their medical care following completion of oncologic or BMT treatment?
Transitions of care are always challenging, especially for patients with complex medical histories, including cancer or stem cell transplantation. There are many different models for how and when to transition patients back to primary care or shared care. The ongoing, often complex needs of survivor...
How do you assess the pros and cons of discontinuing a selective alpha blocker such as tamsulosin or alfuzosin in an older adult male with orthostatic hypotension and established urinary retention?
Discontinuing alpha blockers in older adults with orthostatic hypotension (OH) and urinary retention is rarely straightforward, and the decision hinges on several key points. First, it is important to understand that selective alpha-blockers (tamsulosin, alfluzosin) work by relaxing the smooth muscl...
How did the SPRINT MIND study influence your approach to blood pressure management in older patients at risk of dementia?
In general, results from SPRINT MIND as well as other studies of blood pressure management in older adults have changed my thinking from being conservative in blood pressure management to favoring more aggressive management in patients able to tolerate higher doses or additional medications for bloo...
What criteria do you use to decide when to perform a BAL in hypersensitivity pneumonitis?
Short answer: When the vibes are right. I know that's a flippant answer, but that's an honest-to-God real answer. Long answer: This is really complicated and personally, I'm frustrated by our guidelines and the level of evidence we have for diagnosing HP. To answer the question, it's worth delineati...
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
Not much is known yet about this specific situation—but our growing experience here in New York City suggests it may be safe. We have had several post-BMT patients who were on immune suppression for GVHD become COVID positive who have not had significant problems. Also, we have now treated 8-10 pat...
Do you regularly recommend an immunological workup for patients with suspected immunodeficiency or defer to immunology?
I defer after a very preliminary work-up based on the type of immunodeficiency expected. I try to direct the consult to a provider most likely to have expertise in the problem I suspect. Often, I suggest consulting with a provider at NIH.
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...