Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely recommend a lumbar puncture for patients with suspected ocular or otic syphilis in the absence of additional CNS symptoms?
No, this isn’t necessary, assuming no other evidence of non-ocular/otic neurosyphilis. I recommend management as advised by CDC in the 2021 treatment guidelines (https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf, p. 40). An especially careful neurological exam is advised, includin...
What is the optimal management of pain and loss of function due to pathologic compression fractures?
I explain to my patients if they have an acute compression fracture that they are likely to experience pain for approximately 2-3 weeks that will gradually resolve. I often give them some type of pain relief using Tylenol or ibuprofen and if severe, a more potent analgesic for a short period of time...
How would you approach management of retroperitoneal fibrosis causing ureteral compression that has already caused irreversible loss of kidney function?
I agree with my colleagues and will add some additional thoughts. While I agree that tissue diagnosis is helpful whenever it can be obtained (both to differentiate IgG4-related vs idiopathic RPF and to exclude other causes such as lymphoma, sarcoma, and Erdheim-Chester Disease), it is often the case...
What is your approach to the use of GLP-1 agonists in older adults with diabetes with or at risk of sarcopenia?
This is an important question to keep an eye on, given the broadening use and effectiveness of GLP-1 agonists for various conditions, especially diabetes, and for weight loss. Unfortunately, as is so often the case, major clinical trials in this area do not reflect the heterogeneity of older adults ...
Where does dronedarone fall in your list of antiarrhythmics drugs to use in terms of efficacy and patient selection in contemporary management of atrial fibrillation?
Dronedarone tends to be my last choice for treatment of AF to maintain sinus rhythm of all currently available oral antiarrhythmic meds available in the US - least effective and very expensive drug. I may use it in patients that I believe would be better served with catheter ablation- treatment with...
Would you consider using IVIG for POTS in the absence of any clear autoimmune condition or abnormal antibodies?
I completely agree with the answer above. It would be a pretty rare consideration, overall. Recent placebo-controlled and blinded studies examining the efficacy of IVIG for idiopathic or antibody-associated (FGFR, TSHDS) small fiber neuropathy found no benefit of the treatment in terms of small fibe...
What is the significance of elevated fractionated catecholamines in POTS?
Dear Dr. @Dr. First Last,I don't think we understand the pathophysiology of POTS well enough to comprehensively answer this question.There are a number of technical issues that come into play when drawing serum catecholamines.First of all, many things can elevate catecholamines temporarily: exercise...
Would you consider giving thrombolytic therapy for patients with acute vision loss concerning for CRAO based on history and within the window before any ophthalmological assessment and confirmation?
We have utilized a prior study to give tPA or tenecteplase within 4.5 hours of onset for CRAO. I would not do so, however, without an ophthalmology evaluation to confirm the likely diagnosis and to exclude an alternative diagnosis such as a retinal detachment.
When would you consider switching to or adding on a PCSK9 inhibitor to lipid-lowering therapy following hospital discharge for acute coronary syndrome, in light of the results of the VICTORION-INCEPTION trial, provided LDL is still not at goal?
I don’t think the trial really changed my mind on this. I never really worried about not having ACS patients in the original phase 3 trials, so I had already been using inclisiran when I could in recent ACS patients. I would never switch from a statin to a PCSK9i. Statins are cheap, effective, and w...
Does your approach to cervical cancer screening change in developmentally delayed patients who are not and have never been sexually active compared to non-developmentally delayed patients?
Any screening is only accomplished with a shared decision-making conversation. Screening for cervical cancer can feel very invasive for many people. I talk to the patients and their families/guardians about the risk/benefits of having a pelvic exam and doing cervical cancer screening. In light of th...