Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach a patient on anti-TNF with positive Quantiferon (previously negative) with negative chest x-ray and no symptoms?
Prior to routine screening for latent TB for patients receiving or about to receive TNF inhibitor therapy, there were reports of miliary TB developing after initiation of TNF inhibitors. Therefore, one cannot say that a negative chest x-ray and no symptoms means the patient is not at risk for develo...
When would you consider checking JC virus prior to initiating biologic therapy?
JC is a ubiquitous virus with sero-prevalence in the adult population of 60-70% in most studies. The concern is that in those who harbor latent JC are vulnerable to reactivation and ultimately the development of Progressive Multifocal Leukoencephalopathy (PML). The drug natalizumab used to treat MS ...
Would you stop current immunosuppressive therapy or delay starting immunosuppressive therapy in a patient with aplastic anemia who has been infected with COVID-19?
This is an interesting question. Based on personal communication (Italy, Germany, Israel), we have not seen increased risk for pediatric patients with hematological diseases and COVID-19. There was one case reported in China, but it was inconclusive (nearly 50 y.o. patient with aplastic anemia—seeme...
Do you recommend vitamin K2 supplements in patients with osteoporosis?
The answer, as with most vitamin supplementations, cannot be answered with high-level evidence to support a "yes or no". A bit of background and then a brief review of available evidence.Vitamin K is thought to be important for bone health because it activates several proteins involved in bone forma...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
What do you think about using conventional thoracic imaging methods (e.g., X-ray, CT, etc.) to determine if a pleural effusion is of adequate size to consider thoracentesis?
Generally speaking, CT would be superior as it would allow you to see more volumetric characteristics of the effusion; XR would have a hard time discerning true size, presence of loculations, or trapped lung. The real winner for this application would be bedside ultrasound. This modality would give ...
How often do you recommend performing an advanced lipid panel for monitoring of lipid lowering therapy?
I am late to the responses, but I do not ever order an advanced lipid panel. Our institution does not have it on the lab menu either (one has to go to an outside lab to get it done). Anything needed for CV risk assessment can be gleaned from the history, including family history and a standard lipid...
How do you balance the risks versus benefits of starting a statin in a patient with MASLD and a persistent but mild elevation in their AST/ALT?
I no longer hesitate to start a statin despite mild ast/alt elevation. I might just check lfts again in a few months, but if there is a clear indication for the statin we go ahead and do it.
How do stroke-risk considerations affect your use of atypical antipsychotics for patients with dementia?
Antipsychotics carry a number of risks, including a warning of sudden death in elderly demented patients. If nothing else works for a behavioral problem, you have to use an antipsychotic. Also, for frank paranoia, which is not only causing distress to parents but also to the environment, treatment w...
Do you start bisphosphonates after tapering off menopausal hormone therapy to prevent the rapid decline of bone mineral density?
Women lose one T-score unit (10-12%) of bone mass on average during menopause. Estrogen, as a part of menopausal hormone therapy (MHT), is approved by the FDA to prevent osteoporosis, but not for its treatment. Upon MHT discontinuation, women will experience a period of rapid bone loss, for which st...