Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What outpatient therapies do you recommend for continuous or severe pain from migraine that is refractory to acute therapies?
I assume that what we are dealing with here is what we call a migraine status or status migrainosus. This refers to a migraine headache that has continued well beyond its usual duration, for which we often use the arbitrary three-day mark. We base this mark on the erroneous assumption that migraine ...
Do you routinely continue dual antibiotic coverage or de-escalate to monotherapy based on peritoneal fluid culture sensitivities in patients with relapsing pseudomonas aeruginosa peritoneal dialysis peritonitis after peritoneal catheter removal?
If the peritoneal dialysis catheter has been removed then I would de-escalate to monotherapy based on the fluid culture sensitivities. Monitor clinical response and obtain new fluid samples for analysis if any concern for persistent infection.
Would you offer TPO-RAs to a steroid-refractory chronic ITP patient with history of stroke?
Yes, if needed, though with a bit of trepidation, and it probably wouldn't be my first choice. Second-line chronic ITP treatment can include TPO-RA, rituximab, or splenectomy, and no one treatment is clearly better than the others (Neunert et al., PMID 31794604). Both splenectomy and TPO-RAs have in...
What would be your approach to managing severe ANCA-associated vasculitis in a patient who is also septic from a bacterial infection?
It is prudent to evaluate if the ANCA-associated vasculitis is being triggered by the underlying bacterial infection. Certain clues on the kidney biopsy including diffuse exudative as well as diffuse crescentic [of same age] pattern of injury on light microscopy, intense C3 staining on immunofluores...
What is your strategy to prevent and treat constipation in patients initiating or receiving opioids?
I am a radiation oncologist and palliative care physician.I teach: "the hand that writes the opioids, writes the laxatives - or else it does the disimpaction". Opioid induced constipation is very common, can cause physical and psychological discomfort, and have a major impact on quality of life. It ...
What is your loading dose goal and typical loading regimen for PO amiodarone in patients with atrial fibrillation?
I generally aim for a loading dose of 10 grams. This is a combination of both IV and PO amiodarone administered. For an outpatient, I utilize one of the original dosing schedules consisting of 200 mg TID x 3 weeks, followed by 200 mg daily (although this is a little more than 10 grams). For an inpat...
Are there scenarios in which you would advise using benzodiazepines for the treatment of hyperactive delirium?
The only situation that comes to mind is in patients who have active alcohol or benzodiazepine withdrawal as the etiology of their delirium. Outside of that, I do not use benzodiazepine therapy for delirium due to the risk of adverse effects (including prolonging the delirium) and lack of any data I...
When (if ever) do you recommend taping a patient off of buprenorphine after sustained remission?
I rarely recommend tapering off buprenorphine after sustained remission for opioid use disorder (OUD) because typically, buprenorphine is well-tolerated, risks are minimal, tapering can be challenging, and the risk of overdose after tapering off MOUD is high.Instances when I would consider a taper a...
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...