Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there evidence that certain PPIs provide superior clinical efficacy compared to others in real-world practice?
While there are some differences between PPIs in terms of metabolism, bioavailability, and duration of acid suppression, generally speaking, in clinical practice, the efficacy of different PPIs is comparable. With that said, some differences include dexlansoprazole's dual-release nature which genera...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
What is your preferred analgesic in patients with small bowel obstruction or ileus?
I typically use IV Tylenol ATC if fully obstructed, and IV Toradol if no other contraindications to NSAIDs (and they often are quite prerenal or losing a lot of fluid from an NG tube, so I often don't feel comfortable with more than a couple doses, and if I think they are going to the OR, I do not u...
What dietary advice do you give patients with hyperlipidemia who want to try and manage it with lifestyle changes first?
The first place I usually start with when it comes to patients seeking lifestyle changes for hyperlipedemia is to point them towards dietary changes. My go to diet for this is the PORTFOLIO diet. A researched diet that has been shown in multiple trials to reduce LDL and was even shown to be non-infe...
What dietary advice do you give patients with hyperlipidemia who want to try and manage it with lifestyle changes first?
The first place I usually start with when it comes to patients seeking lifestyle changes for hyperlipedemia is to point them towards dietary changes. My go to diet for this is the PORTFOLIO diet. A researched diet that has been shown in multiple trials to reduce LDL and was even shown to be non-infe...
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...
How do you decide between anticoagulation and observation for an incidentally detected subsegmental pulmonary embolism in elderly patients with a history of gastrointestinal bleeding?
We face this conundrum not infrequently because subsegmental emboli are subject to high inter-reader variability, and the accuracy of the finding in isolation is suspect (Batayneh et al., Blood 2023). I once mentioned this to a radiologist who reads CTAs and was told, tactfully, that I was full of i...
How do you approach initial steroid dosing in patients with eosinophilic fasciitis?
I usually start with a high dose at 60 mg daily for a few weeks, then add DMARDs like MTX.
How do you decide when to treat hypocalcemia in hospitalized patients?
When I think about when to treat hypocalcemia in hospitalized patients, I anchor the decision on three things: symptoms, the absolute calcium level, and the trajectory. First, it’s important to confirm true hypocalcemia: either a serum calcium <8 mg/dL or an ionized calcium <1.1 mmol/L, and to consi...
In a patient with sicca symptoms and SS-B antibodies only, can a minor salivary gland lip biopsy with lymphoid aggregates, but also scattered areas of acute neutrophilic inflammation be consistent with Sjogren's Disease?
I agree with @Dr. First Last and cannot speculate on the neutrophils.I'd also like to point out that a French study showed that only 1% of isolated anti-SSB patients had Sjogren's disease, SjD (Jardel et al., PMID 28931060); all others had other autoimmune diseases, neoplasia, infection, and solitar...