Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
When do you consider starting medications such as metformin or a GLP-1 RA for the purpose of DM prevention in patients whose A1c% is not in the diagnostic range but demonstrates progressive weight gain/metabolic dysfunction?
Realistically, starting a GLP-1 is almost entirely dependent on whether insurance covers the medication or not. Given that Medicare/Medicaid covers the medicine for diabetes, OSA, cardiovascular disease, or MASH, I find it is often difficult to get it covered solely for obesity unless they have cert...
How do you counsel patients who are considering stopping a GLP-1 agonist after achieving their weight loss goal, now that long-term maintenance data suggest most will regain a substantial portion of their weight within a year of discontinuation?
Great question! I actually incorporate this knowledge into my initial medication counseling to see whether patients are comfortable being on this medication chronically. I let almost everyone know that coming off the medication will likely lead to significant weight gain, and that comes with signifi...
Do you utilize the bronchiectasis severity index (BSI) in your approach to managing non-CF bronchiectasis?
I calculate it for academic reasons in my bronchiectasis clinic. It perhaps affects the frequency of visits in the clinic. Otherwise, not much practical application. I respond to daily cough and secretion management with stepping up airway clearance, and to frequency bronchiectasis exacerbations wit...
What alternative, low-effort airway clearance strategies do you use in frail neuromuscular patients who are unable to tolerate or fail manual chest physiotherapy (e.g., oscillating PEP devices, high-frequency chest wall oscillation vests, or mechanical insufflation-exsufflation/cough assist)?
Airway clearance is key to quality of life and prolonged survival in frail NMD patients, sometimes adding decades, depending on the particular NMD and other factors (luck and prayers don't hurt). Most tolerate manual techniques (i.e., quad coughing) reasonably well, so I wouldn't wait for them to no...
How do you characterize pleural effusions on POCUS between trace, small, moderate, and large?
Assuming the effusion is free-flowing and not loculated, there are a few equations out there that can help quantify pleural effusion volume based on whether the patient is supine at max inspiration, supine at end-expiration, or sitting upright. In my hospitalist practice, I don't usually calculate b...
Do you recommend the use of portable high-efficiency particulate absolute air cleaners to former smokers with moderate to severe COPD?
This is a regional decision that is based upon ambient air pollution, such as wildfire smoke in the Southwest, and can be trialed before purchase to evaluate symptomatic efficacy. The CLEAN AIR STUDY (Hansel et al., PMID 34449285) did not validate improvement in total St George's Respiratory Questio...
How long do you recommend patients hold aspirin for prior to and after undergoing a native kidney biopsy?
I usually recommend that patients hold aspirin (ASA) 7 days prior to and one day after undergoing a percutaneous native kidney biopsy. 30 mg of ASA irreversibly inhibits cyclooxygenase a key platelet enzyme for the synthesis of thromboxane and the effect lasts for approximately one week. This effect...
How do you reconcile the risk of contrast-induced nephropathy (CIN) with the diagnostic benefit of contrasted CT in patients with AKI/CKD?
Overall, the risk of contrast-induced nephropathy is much less than what we fear. In many studies, we underutilize CT because we're concerned about contrast-induced nephropathy. If there is a good reason to get the CT with contrast, then I think it should be done. And just monitor Cr.
What class(es) of antihypertensives should be considered next for refractory hypertension in a patient compliant with high doses of Entresto, chlorthalidone, amlodipine, clonidine, and spironolactone if they previously did not have any improvement on beta blocker or hydralazine and work-up for secondary causes were unremarkable?
Minoxidil remains a rarely used but potent option.
Do you perform pap smears as part of the surveillance of patients with a history of cervical or vaginal cancers who had radiation as part of their treatment?
I personally do not routinely perform pap testing for patients with a prior history of cervical or vaginal cancer who have had prior radiation. The main driver for me in this decision is that the results we receive from Pap testing often show abnormalities that are not reflective of recurrence or de...