Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
What is your approach to iron supplementation in patients with an active infection?
In patients with active infections, I generally avoid intravenous iron due to the potential for promoting pathogen growth, a practice supported by cautions from nephrology and gastroenterology society guidelines. However, evidence for the risk of infection with IV iron is inconsistent, underpowered,...
Do you recommend checking anti-drug antibodies for patients on TNF inhibitors?
This is a very good question with direct clinical practice implications. I do not check or follow anti-drug antibodies when using TNF inhibitors for the treatment of rheumatoid arthritis or psoriatic arthritis. There are reports that suggest, on a group level, that these antibodies, if present, impa...
What is the appropriate cardiac work-up and management for an otherwise healthy individual who has experienced immersion pulmonary edema while scuba diving?
Immersion pulmonary edema (IPE) is rare in the general population, but does occur in approximately 1% of triathletes and more frequently among military recruits (Kumar and Thompson, PMID 30403902). IPE is due to acute increases in pulmonary capillary wedge pressure (PCWP), which can flood the alveol...
How do you approach rising PSA following radical prostatectomy and early salvage radiation therapy?
There are several factors that I will take into consideration, including the patient's overall health, the interval from treatment to relapse, the PSA doubling time (rather than a PSA threshold), whether or not they're castrate resistant and whether or not they now have overt metastatic disease. Pat...
When and how should we use biomarkers (i.e., CRP, stool calprotectin, mAb levels) to guide or optimize medical management of Crohn’s disease or ulcerative colitis?
The principal clinical applications of biomarkers in IBD are as follows: Assessment of severity and prognosis during a flareup. Monitoring the efficacy of treatment. Determining the probability of postoperative recurrence of Crohn’s disease (i.e., the high negative predictive value of FPC for anasto...
In patients with an acute gout flare who have stage 3–4 CKD or are on anticoagulation, what is your preferred first-line treatment?
This is a challenge. Intra-articular steroids may be the best option. Colchicine is an extremely complicated issue. A single dose of colchicine at 0.3 or 0.15 mg might be considered. Systemic steroids probably should be avoided because they reduce resistance to infection in an already compromised in...
Have you changed your approach to delaying hip surgery in the context of decompensated CHF given the findings of the HIP-ATTACK study?
That is an interesting question. Patients with a hip fracture have a high mortality, and delaying surgery could contribute to this mortality. On the other side of the pendulum is acute heart failure. Patients with acute heart failure have increased mortality in the perioperative period. Some of this...
How do you balance the risks and benefits of stimulant treatment in patients with poorly controlled hypertension?
The short answer is that there are no clear cutoffs to clearly guide management, and often decisions are guided by shared decision making with patients and relevant specialties (psychiatry, primary care, cardiology).Clinical factors which may prompt you to stop or reduce stimulants: Elevated BP that...
What therapeutic approaches have you found effective for athletes with anorexia nervosa whose eating disorder symptoms are intertwined with sport-driven weight pressures?
The gold standard for treatment of anorexia nervosa and all eating disorders is a team-based approach, including the individual, psychiatrist, counselor, primary care or sports medicine physician, dietician, appropriate family members, and, in the case of elite athletes, sometimes their coaches. Rap...