Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are there certain sedatives or anti-epileptic meds to avoid in patients with IDD?
They are very interesting questions and I think “do no harm” relates to the issue of using any medication, whether it's an anti-epileptic drug or something for pain, or anything. Any medication can have an impact. When you think about someone with an intellectual or developmental disability (IDD) w...
What workup do you perform for elevated B12 levels in an adult who is not taking supplements?
There is no convincing evidence of the harmful effects of elevated serum B12 per se, so I have not vigorously pursued this lab finding. If excessive supplements are consumed, B12 is innocuously excreted in the urine once tissue receptors are saturated. Nonetheless, this question raises some interest...
Is there a correlation between spleen size and degree of thrombocytopenia?
In a normal individual, approximately 1/3 of total body platelets are sequestered in the spleen at any given time. As the size of the spleen increases, so too does the proportion of platelets in the spleen increase. This is due to the total volume of the spleen, not just longitudinal measurement. It...
Can romosozumab be used in patients on dialysis?
This is an interesting question given the common finding of osteoporosis among patients undergoing hemodialysis. There have been several individual case reports suggesting that treatment with romosozumab in this patient population can be safe and effective. The largest study (no control group) of wh...
Do you hospitalize patients with newly diagnosed lupus nephritis and nephrotic syndrome if you are able to provide pulse steroids outpatient and follow them closely?
Usually not. I suspect it all depends upon one's ancillary support situation. We are able to do in-house labs, give immediate in-house IV pulse steroids, and I can call interventional radiology and get an ASAP renal biopsy. If there were complications, such as infection, thrombosis, need for dialysi...
What is your preferred rate control agent for atrial fibrillation with rapid ventricular rate, and why?
It really depends on the clinical scenario. My preferred first line agent is short acting metoprolol. Non-dihydropyridine calcium channel blockers such as diltiazem or verapamil are also effective but should generally be avoided in patients with reduced LVEF. In hospitalized patients with tenuous he...
What is your preferred rate control agent for atrial fibrillation with rapid ventricular rate, and why?
It really depends on the clinical scenario. My preferred first line agent is short acting metoprolol. Non-dihydropyridine calcium channel blockers such as diltiazem or verapamil are also effective but should generally be avoided in patients with reduced LVEF. In hospitalized patients with tenuous he...
What is the expected timeframe one would expect to see paroxysmal sympathetic hyperactivity/sympathetic storming persist post-traumatic brain injury?
I've personally seen as long as 30+ days but usually less.
What is the management strategy for patients who develop AKI and nephrotic range proteinuria secondary to biopsy proven FSGS during immune checkpoint inhibitor therapy?
For glomerulonephritis induced by ICI would recommend rituximab 1 gram for a total dose of 2 doses 2 weeks apart. Based on limited case reports there has been a good response to rituximab with maintained remission of glomerulonephritis and the ability to continue on ICI without relapse. Please refer...
Would you transition from IV to oral antibiotics in a solid organ transplant recipient with uncomplicated gram-negative bacteremia?
Yes, I would in the right circumstances. The referenced article by Nussbaum et al., PMID 38195100 provides reasonable evidence that this is a valid approach. Particularly, if the patient's net-state-of-immunosuppression is not terribly high and the organism is susceptible to highly bioavailable oral...