Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How should we approach the recommendation of intermittent fasting for weight loss in patients with pre-existing cardiovascular conditions, given the observed association of increased CV mortality with eating durations of less than 8 hrs?
I will admit my prejudice on this topic. I don’t understand the biologic plausibility of shortening the time during which meals are consumed to 8 consecutive hours a day with no snacking for 16 hours a day (but without calorie restriction) in order to lose weight. This would be like saying “have bru...
How would you treat an asymptomatic patient with a positive Blastomyces antibody, evidence of prior granulomatous lung disease on imaging, and who may require immunosuppression in the future?
We practice in an area with a good bit of blastomycosis and rarely see a positive Blastomyces antibody, even in patients with culture-proven blastomycosis. The newer EIA antibody that MiraVista lab is doing may be more reliable. If the prior granulomatous lung disease has been worked up with negativ...
What varying approaches do you take in suicide risk assessments?
I agree with the following from Dr. @Dr. First Last: "Ultimately, no scale or method is going to be perfect. We are unfortunately bad at predicting which individuals with suicidal ideation progress to an attempt. The most we can do is gather as much information as possible about how someone is feeli...
What is your approach to patients with biopsy proven giant cell arteritis that continue to have symptoms after initiation of high dose glucocorticoid therapy?
First, let's define and discuss “high-dose” steroids. Oral therapy is typically 60-100 mg of prednisone daily, and IV is 500-1000 mg of methylprednisolone daily for three days, followed by oral prednisone. There has been no difference in long-term outcomes for vision loss or diplopia. The complicati...
How do you determine the severity of restrictive lung disease?
My interpretation of the latest ATS/ERS guidelines is that FEV1 should be used for "any spirometric abnormality" including restriction or mixed disorders, which is unchanged from the 2005 ERS Guidelines.That said, I tend to use FVC when grading pure restrictive disorders, habituated as a result of F...
Have any studies shown that testosterone replacement therapy lowers the incidence of prostate cancer in hypogonadal men, or is the evidence still largely neutral?
This is a broad question to which I will give a broad answer.For men with hypogonadism (symptoms and signs of androgen deficiency, reproducibly low serum testosterone with an accurate, reliable assay) and no reversible cause, the epidemiological data overall do not show evidence of increased risk of...
Is there an age cutoff where you consider the risks of monoclonal antibody therapy outweigh any potential benefit(s) in early-onset dementia?
A brief discussion of dementia terminology is worthwhile to avoid confusion regarding diagnostic classification and treatment rationale. As is well known, there are many dementias, and the descriptor “early onset” can be used for childhood dementias, such as Rett syndrome, and also for disorders suc...
Do you escalate treatment in patients with myositis who achieve clinical remission but continue to have elevated CPK?
Typically, patients who are doing well and in remission can have low levels of CK abnormality, which needs to be monitored but not treated. Post myositis improvement, some patient's muscle membrane remains leaky or not perfect, leading to some low levels of elevated CK, which has no clinical signifi...
How do you manage gram-negative bacteremia in a patient with an aortic bypass graft, for whom there is low clinical suspicion for active graft infection?
This is a very nuanced question, and thus, there is no perfect answer. If there is low suspicion for graft infection and the bacteria is not commonly associated with biofilms (like a simple E. coli) and the bacteremia clears quickly, I would likely treat for a couple of weeks and monitor (and even c...
How do you approach the use of benzodiazepines in patients with chronic medical illnesses that may be susceptible to respiratory compromise (e.g., CHF, COPD, ILD)?
It’s a very good question and answers may vary among different specialty providers. Yes, a slow or gradual weaning of the benzodiazepines would be advisable. When they reach lower doses the taper should be even slower over weeks or longer. There is a risk for not weaning them off benzodiazepines inc...