Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you usually introduce conversations regarding tracheostomy placement in patients with refractory status epilepticus, or other conditions where one may anticipate delayed awakening?
It depends on the underlying pathology and how long the patient is expected to have impaired airway reflexes requiring prolonged mechanical ventilation. In the Setpoint 2 trial, among patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy (</= 5 days), compare...
What is the utility of a hypercoagulability workup in recurrent cryptogenic stroke, and what specific tests would you recommend?
Ambulatory monitoring for AFib is probably more helpful than such a thorough clotting workup.
Should GLP-1 agonists be held during chemotherapy?
I think there are several aspects to this question. First, is there evidence that as a class GLP-1 RAs increase the risk of cancer or worsen prognosis during cancer? I could find nothing to raise concerns about outcomes. One recent report even showed a decreased risk of some cancers with GLP-1 RA co...
What parameters would you use to monitor and interpret iron levels in a hemochromatosis patient where ferritin is unreliable due to underlying chronic inflammation?
The biggest question in these situations is whether the patient truly has iron overload vs. just high ferritin. If iron sat is not elevated, true iron overload is very unlikely. If both ferritin and iron sat are elevated, but they don't have a homozygous C282Y genotype, I make sure that the patient ...
Do you recommend that your patients with COPD avoid gabapentin or pregabalin entirely, given the increased rate of exacerbations noted in patients on these medications?
No, I don't exclude gabapentin or pregabalin as therapeutic options for patients with COPD. The study of Rahman is a cohort study that suggests an interesting association but has limitations, including residual confounding variables and a lack of smoking information on the study population. The issu...
When discontinuing Denosumab after more than 2-3 years of therapy, when do you recommend giving the first dose of zoledronic acid?
My practice has been that after 2-3 years of denosumab, I wait 6 months and then start zoledronic acid.
What duration of antibiotic therapy do you use for a loculated parapneumonic effusion that does not meet criteria for empyema?
It would be great to see more prospective research in this area. I think we should be a bit more nuanced in our approach as it seems to be crude to recommend 4 to 6 weeks of IV antibiotics for every parapneumonic effusion or complicated pleural space. I think that in melding the IDSA and American As...
Do you routinely use cefdinir for the treatment of common infections diagnosed in the outpatient setting such as CAP, uncomplicated UTIs?
Not routinely. More expensive than equally effective alternatives.
What is your general approach to an immunocompetent patient with chronic, non-infectious diarrhea?
If the diarrhea has lasted more than a few weeks and all infectious workup is negative, then I'll send serologies for IBD/celiac, especially if there is any weight loss. Where we practice in New York City, these patients almost always end up getting an EGD/colonoscopy.
Are drug challenges after serum sickness-like reactions useful in delabeling the allergy?
Too unpredictable each time.