Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
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...
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 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.
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.