Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
For patients with Hashimoto's thyroiditis, is there a commercially available blood test for detecting abnormalities in the type 1 deiodinase enzyme in order to identify patients who would potentially benefit from T4 and T3 combination therapy?
From a clinical standpoint, there is almost never a need for adding T3 to the therapeutic regimen of patients being treated for hypothyroidism. The exogenously provided T4 gets converted to T3 in the body. Why pay the drug companies a lot of money for something that your body will do for free? The T...
Do you empirically administer high-dose IV thiamine to all patients admitted with sepsis and a history of alcohol use disorder, even without clinical signs of Wernicke encephalopathy?
There is little to no downside risk for thiamine administration in comparison to severe morbidity for the failure to use thiamine, as supported by a recent review (Teixeira et al., PMID 39818490).
What are your thoughts on the results of the ALONE-AF trial and the safety profile of discontinuing anticoagulation post-ablation, provided there is no atrial arrhythmia recurrence?
ALONE-AF is another recent trial to challenge the current dogma. The 2023 ACC/AHA/HRS guidelines for AF recommend "In patients who have undergone catheter ablation of AF, continuation of longer-term oral anticoagulation should be dictated according to the patients’ stroke risk (e.g., CHA2DS2-VASc sc...
Do you recommend starting a statin in patients above 75 years old with diabetes but no known ASCVD?
The time to benefit (TTB) for statins in primary prevention of cardiovascular events is generally about 1.5 to 3 years. This means that adults aged 50 to 75 years typically need to take statins for at least 2.5 years to achieve a meaningful reduction in major adverse cardiovascular events (MACE), su...
What is your systolic blood pressure target for patients over 80 with frailty and multiple comorbidities?
The target of 150/90 mmHg for adults over 80 primarily comes from the HYVET study, which demonstrated benefit in reducing stroke and mortality in this age group. However, as with all decisions in geriatric care, treatment should be individualized and guided by the patient’s functional status and goa...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
How would you approach the upfront management of a patient with acute unilateral vision loss with strong clinical risk factors for both cardioembolic stroke and GCA if an expedited MRI is not possible due to the presence of an AICD?
I'm definitely not an expert in this topic, but you have many clinical tools to increase/decrease your clinical suspicion for GCA vs. cardioembolic stroke. Some things I would ask: Is this patient currently in Afib? What's their CHADSVASC? Are they anticoagulated? Can we get a TTE to check for vege...
Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?
In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...
Do you ever use Joyrnavx in a patient with end stage liver disease?
I have not encountered this novel oral small molecule medication Suzetrigine for the management of acute moderate to severe pain (FDA approved indication) in my patients with cirrhosis. The drug received FDA approval in Jan 2025 after two phase III trials where it was used for pain control after b...
Do you ever use Joyrnavx in a patient with end stage liver disease?
I have not encountered this novel oral small molecule medication Suzetrigine for the management of acute moderate to severe pain (FDA approved indication) in my patients with cirrhosis. The drug received FDA approval in Jan 2025 after two phase III trials where it was used for pain control after b...