Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you counsel older adults regarding the use of melatonin (dose and timing) for sleep-related problems?
Melatonin is likely helpful, but patients need to feel comfortable that the melatonin they bought actually contains melatonin, so it's best to suggest that they buy products that have been separately tested. I also feel the need to keep circadian rhythms in mind, so I try to have patients take it as...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
Do you have any concerns about administering a Vivitrol injection when a patient has severe coagulopathy and/or thrombocytopenia related to cirrhosis?
Although the risk of transaminitis is overall low, I do try to be more conservative when patients have evidence of severe cirrhosis or decompensated cirrhosis. If naltrexone is the best choice, I will typically start with oral naltrexone and check labs to ensure that they are stable. And if the pati...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
Are there still clinical situations in which you deliberately treat patients with a DOAC besides apixaban?
Thank you for your question. Apixaban has been my preferred agent for a long time for patients requiring therapeutic anticoagulation. Apixaban’s lower bleeding risk was shown prior to and now has additional evidence to support this with the COBRRA trial. The risk is also ameliorated by the safety in...
What should the LDL target be in patients with prediabetes and high lipoprotein (a) with family history of coronary artery disease?
I don’t think that using Lp(a) to guide treatment is quite ready for prime time yet. It’s an independent predictor of risk compared to the rest of the lipid panel, but as far as I am aware, we do not yet have data that treating people based on it makes a difference. What I may do in this scenario is...
How would you approach a patient with a recent MI s/p DES who is being considered for neoadjuvant chemotherapy for TNBC?
This is mostly opinion as there is not data specific to this situation. First, I would coordinate closely with the cardiologist, preferably someone with knowledge of cardio-oncology. Presumably the patient is already on cardioprotective medications, such as beta blocker and ACE inhibitor, but if not...
What is your antipsychotic of choice and general titration regimen in the outpatient setting for a patient with dementia and behavioral disturbances (assuming reversible causes such as urinary retention, constipation, etc. have been addressed)?
While not set in stone and knowing that there is a black box warning, make sure you get informed consent. I start with low doses of quetiapine (12.5 to 25 mg), as it has the shortest half-life, and will use it twice or 3 times a day. This allows for quicker recovery if they are too sedated. Dependin...
How do you approach DOAC dose reduction for secondary prophylaxis of VTE in cancer-associated thrombosis?
Data from the API-CAT trial (Mahé et al., PMID 40162636) show that de-escalation of apixaban after 6 months was non-inferior compared to the standard dose with respect to recurrent VTE. Although there was no difference in major bleeding, the lower dose of apixaban was superior from the clinically re...
How soon after excising a keloid do you inject kenalog?
I ran into this issue in clinic a few months ago when I started doing keloid excisions on patients' ears - there's some decent data in the following article for doing immediate kenalog injections without impairing wound healing.Burusapat et al., PMID 34367855