Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach titration or transitioning to Cobenfy in patients currently on an antipsychotic?
Antipsychotics with significant anticholinergic activity, such as olanzapine and clozapine, can add to the effects of trospium contained in xanomeline-trospium combination. Product labeling reads "Concomitant use of COBENFY with other antimuscarinic drugs that produce anticholinergic adverse reactio...
Should we be recommending a specific daily protein intake to prevent sarcopenia in geriatric patients, or do you find it more beneficial to focus on encouraging activity within their mobility limitations to preserve muscle mass?
Muscle mass decreases about 3–8% per decade after the age of 30, with this rate of decline increasing after age 60. (Holloszy, PMID 10959208 and Melton et al., PMID 10855597). Hospitalizations also cause acute muscle loss, disproportionately more in older adults."Among medically stable older adults,...
What is your approach to using beta-blockers in patients with acute myocardial infarction with preserved LV ejection fraction who undergo early coronary angiography in light of the REDUCE-AMI trial findings?
I would not change practice based on the findings of this study alone. Treatment cross-over in both arms of the study may obscure the potential benefits of post-MI beta-blocker therapy in patients with preserved EF.
Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?
Hypocalcemia can be prevented by providing adequate calcium, 1,200-1,500 mg in divided doses daily, and adequate calcitriol to absorb it. Good results also occur when the patient has tertiary hyperparathyroidism with hypercalcemia.
How do you manage persistent cytopenias after FCR chemotherapy for treatment of CLL?
For persistent cytopenias after FCR, the initial approach would be supportive care. If no recovery after 12 weeks, consideration should be for a bone marrow biopsy to evaluate for aplasia, an autoimmune process like PRCA, or early MDS. The therapy after the bone marrow would be based on the result. ...
What are some helpful tips to identify and optimize visualization of the common bile duct on abdominal POCUS?
Good question! The common bile duct (CBD) can be difficult to visualize in general, but optimizing the gallbladder exam will also help to optimize the CBD. I am cautious about ruling out choledocholithiasis with POCUS, though a retrospective 2014 study showed that POCUS can be helpful in ruling out ...
What are some helpful tips to identify and optimize visualization of the common bile duct on abdominal POCUS?
Good question! The common bile duct (CBD) can be difficult to visualize in general, but optimizing the gallbladder exam will also help to optimize the CBD. I am cautious about ruling out choledocholithiasis with POCUS, though a retrospective 2014 study showed that POCUS can be helpful in ruling out ...
How do you counsel patients with AUD about non-alcoholic (NA) beverage consumption?
I am not aware of any data to help with answering this question, so I am here offering my expert opinion only. I think of non-alcoholic beverages similar to how I think about vaping nicotine. There are incontrovertible harms associated with both alcohol and inhaled tobacco. The harms of vaping nicot...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
For patients immediately recovered from DKA (e.g., within 72 hours), my first priority would be to delay any non-emergent surgery until the etiology of DKA has been evaluated and (if possible) addressed and the DKA has been definitively resolved with conversion off of continuous insulin and resumpti...
Do you change your pre-operative insulin dosing when patients are NPO for surgery, but also just recovering from newly resolved DKA?
For patients immediately recovered from DKA (e.g., within 72 hours), my first priority would be to delay any non-emergent surgery until the etiology of DKA has been evaluated and (if possible) addressed and the DKA has been definitively resolved with conversion off of continuous insulin and resumpti...