Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider using stimulants in patients with cognitive impairments secondary to traumatic brain injury?
Perhaps most importantly, prescribing medication to address cognitive difficulties conveys hope to TBI patients that even if they have suffered structural brain damage, they can improve. Though the improvement may be fairly small, it can have important implications for better general functioning. We...
How has COVID-19 altered your recommendations for invasive mediastinal staging for NSCLC?
I just had this discussion with our chief of interventional pulmonolgy at MD Anderson. Some of his faculty are being asked to staff our COVID-19 patient floor. In addition, bronchoscopy procedures should be considered high-risk procedures, and are required to have at least 45 minutes in between proc...
Do you continue TNF inhibitors in patients with a new diagnosis of CLL?
If the patient does not require any treatments for CLL that are potentially immunosuppressive, I would continue TNF-inhibitor therapy in this setting. It is always helpful to discuss the case with the patient's hematologist/oncologist to make sure everyone is comfortable with the plan.
When do you consider pharmacologic therapies such as sodium tablets, urea, vaptans, etc., vs conservative management for persistent asymptomatic hyponatremia in hospitalized patients?
For patients with SIADH, I consider active therapy in one of the following scenarios: Na remains <130, especially <125–128, despite 24–48 h of appropriate conservative management. Fluid restriction is not feasible (thirst, tube feeds, need for hydration, patient cannot adhere). The patient has recu...
When do you use seizure prophylaxis in patients on clozapine?
The topic of the use of anticonvulsants for primary prophylaxis of clozapine-induced seizures continues to be debated. The idea of prescribing anticonvulsants prophylactically for patients taking >600 mg/day of clozapine was suggested by Devinksy et al., PMID 2006003 in 1991. Clozapine-induced seizu...
How do you manage catheter-associated, upper extremity superficial venous thrombosis?
I manage catheter-associated upper extremity superficial venous thrombosis (SVT) conservatively with arm elevation, warm compresses, NSAIDs, and topical creams containing NSAIDs. Upper extremity SVT is primarily caused by indwelling intravenous catheters, so I do strongly recommend catheter removal ...
Which factors favor extended dual antiplatelet therapy beyond one year in ACS patients with low bleeding risk?
Selecting an optimal duration of dual antiplatelet therapy (DAPT) for a given patient (whether "extended" or "short" in comparison to one year) must be personalized, with a calculus that considers an individual's competing risks of bleeding and thrombosis as a function of time.Accordingly, without b...
Do you find adding fludrocortisone helpful in treating persistent hypotension in HD patients already on midodrine and without evidence of adrenal insufficiency?
That is not my practice. I doubt it would be helpful.
Do patients with central adrenal insufficiency on maintenance hydrocortisone therapy require doubling of their corticosteroid during chemotherapy cycles?
I would follow the same sick day rules. If the patient is not feeling well with nausea, diarrhea, or worsening fatigue, the same rules of doubling the GC dose would apply. In cases of severe vomiting and not being able to keep the double dose of GC, parenteral GC injection and going to the ED for fl...
How many days prior to surgery do you recommend stopping SGLT2 inhibitors and when is it safe to resume therapy?
SGLT2-inhibitors have been known to precipitate episodes of diabetic ketoacidosis(DKA) with glucose levels far lower than are usually seen in DKA. This has been called euglycemic DKA. SGLT-2 inhibitors cause an increase in the glucagon to insulin ratio, which promotes ketosis, as well as fluid loss ...