Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is your approach to managing immune related adverse events altered at all in light of COVID-19?
First of all, I wish to thank @Dr. First Last from Johns Hopkins/Sibley for his advice addressing this critical topic.We are all witnessing a rapidly evolving crisis that none of us have been prepared for and it is the right thing to quickly consider as best as we can how the COVID-19 pandemic shoul...
How do you follow patients after SBRT for NSCLC?
When we started our lung SBRT practice almost 13 years ago, the follow up schedule was based on trying to measure the benefits and impact of the therapy in a fairly structured fashion so that we could develop expertise in understanding outcomes, radiographic changes, patient experience, and treatmen...
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...
Is there a role for monitoring PTH levels in patients with advanced chronic kidney disease who are receiving denosumab in order to assess for adynamic bone disease?
It is more important to monitor PTH and bone-specific alkaline phosphatase prior to the initiation of denosumab. If PTH and bone-specific alkaline phosphatase are suggestive of adynamic bone disease, I would recommend a bone biopsy to rule out adynamic bone disease prior to the initiation of denosum...
How long would you wait before performing a kidney biopsy in a patient with possible AIN whose creatinine has plateaued, but not improved, after discontinuing the suspected offending agent?
If the kidney function has not resolved one week after withdrawal of the suspected offending agent, I would request a biopsy.
How do you decide whether to prescribe electrolyte supplementation at discharge for patients with persistent mild derangements?
I would only prescribe electrolyte supplementation at discharge for mild derangements if there is a clear medical/medication-related reason (such as a new diuretic) and would ensure the patient has close outpatient follow-up.
Would you initiate antifibrotic therapy in a patient with CTD-ILD experiencing worsening symptoms and declining lung function, despite no clear evidence of fibrosis on CT scans?
If the predominant findings on CT were ground glass opacities and/or nodules without any evidence of fibrosis on CT, I would not start with an antifibrotic and, instead, would start with immunosuppression as a first-line agent. Based on the American College of Rheumatology (ACR) and American Thoraci...
In a frail older adult with moderate-to-severe lower urinary tract symptoms, when do you start a beta-3 agonist like vibegron over an anticholinergic?
In a frail older adult with OAB-predominant moderate-to-severe LUTS, I generally start a β3 agonist (vibegron or mirabegron) as the first-line pharmacologic option once behavioral interventions are insufficient. Behavioral therapies may include fluid management, bladder retraining, pelvic floor exer...
How do you counsel older adults regarding the use of melatonin (dose and timing) for sleep-related problems?
Although many patients take up to 10 mg of melatonin, in older adults, the data support doses in the 2-4 mg range (dose response peaks at 4 mg for sleep). I find 30 minutes is not long enough prior to desired sleep time, and I try to give it to hospitalized older patients at about 7 pm so they can f...
What clinical features during a heart failure hospitalization make you defer SGLT-2 inhibitor initiation to outpatient follow-up rather than starting in-hospital?
I have witnessed clinical practice evolve considerably over the past few years on this topic, and there is now increasing emphasis and consensus around initiating SGLT-2 inhibitors during a heart failure hospitalization rather than waiting until after discharge. Evidence suggests that benefits begin...