Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When home BP readings are consistently lower than office measurements, how do you decide whether to intensify, maintain, or de-escalate antihypertensive therapy?
If the home readings can be confirmed to be appropriately measured (i.e., in a hard-backed chair with arm support and checking multiple repeated readings), then I will adjust BP medications to target the average home BP of <130/80 (going lower toward 120/80, if tolerated). However, I have had patien...
How should clinicians balance the use of finerenone with other heart failure treatments like SGLT2 inhibitors, considering their glycemic benefits?
Finerenone could replace spironolactone or eplerenone since the likelihood of adverse effects are less. Unfortunately, RCTs of finerenone have compared it placebo. Until superiority to spironolactone (a cheap and very effective drug for heart failure) is shown we cannot justify the cost.
Do you maintain a strict platelet threshold of >50k when performing a lumbar puncture, or are there situations in which you feel comfortable with a lower threshold?
Our institution still uses 50k as a best practice guideline, though many of our proceduralists are comfortable performing the procedure with platelets slightly lower than 50k, and will have a risk/benefit discussion with the patient/team about the bleeding risk prior to proceeding; I myself would be...
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...
For opiate-related ileus in the postoperative setting, at what point do you consider trialing methylnaltrexone?
I personally have never used this particular PAMORA for post-op ileus. Despite some promising phase 2 trials indicating potential benefit, several Phase 3 RCTs evaluating this drug specifically for post-operative ileus showed no benefit in preventing nausea/vomiting or speeding up time to discharge ...
For opiate-related ileus in the postoperative setting, at what point do you consider trialing methylnaltrexone?
I personally have never used this particular PAMORA for post-op ileus. Despite some promising phase 2 trials indicating potential benefit, several Phase 3 RCTs evaluating this drug specifically for post-operative ileus showed no benefit in preventing nausea/vomiting or speeding up time to discharge ...
Do you obtain liver biopsy to confirm the diagnosis of cirrhosis if cirrhotic liver morphology is noted on imaging?
This question touches upon two interesting trends: 1) There is an increasing trend in Radiology to report "cirrhotic liver morphology" in the "Impressions" section. When you then review the Body of the report, often these cases are noted to only have a heterogeneous appearing liver with surface nodu...
What pharmacologic and non-pharmacologic strategies have you found helpful in managing brain fog following COVID-19 infection?
In general, a systematic approach should be taken to evaluate COVID-19-related brain fog, which can then guide treatment. Additionally, brain fog following COVID infection can often be multifactorial, and the treatment accordingly often needs to be multi-pronged and comprehensive. The recommendation...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...
Do you routinely hold anticoagulation (including pharmacologic VTE prophylaxis) for bedside procedures such as paracentesis, thoracentesis, and central venous catheter placement?
We do not hold anticoagulation of any kind for paracentesis. I also do not hold anticoagulation of any kind of thoracentesis, though some places will still ask things like Plavix or DOAC to be held. We do hold ppx and anticoagulation for LP due to the risk of epidural hematoma. I do not hold for the...