Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Do you routinely order karius in evaluation of culture negative prosthetic valve endocarditis?
Don’t “routinely” order Karius test. Rarely, in culture-negative suspected endocarditis, especially if a prosthetic valve is present. Once for suspected culture-negative aortic graft infection. 3x for culture-negative meningitis. Likely to become more frequent but adoption very dependent on cost an...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...
What are your preferred non-benzodiazepine therapies for the hyperactive/agitated phase of methamphetamine withdrawal, both in the hospital and in the office?
In our outpatient substance use disorder practice, we tend to use lisdexamphetamine (Vyvanse) at fairly high doses off-label for patients with meth withdrawal. We establish a buddy system preferably with someone who lives with them, provide Suicide hotline phone number, describe reasons to transport...
What is your approach to managing incidental hypertension without evidence of end-organ damage in hospitalized patients?
Approaches to managing inpatient HTN without evidence of end-organ dysfunction have evolved over the years. I worked with some attendings who felt strongly about treating. There was a great JAMA IM article that explored this very question for non-cardiac patients. Link here: Rastogi et al., PMID 333...
Do you routinely treat patients with neurosyphilis with IM penicillin for 1-3 weeks after completing a full treatment course of IV penicillin?
The same question was asked almost exactly two years ago. Repeating the same reply with minor edits: This has been a topic of a debate among syphilis experts for decades. There are no data at all on whether there is benefit (e.g. in preventing later relapse) in adding low-dose but long-acting penici...
What studies do you find helpful to determine if an axial spondyloarthritis patient presenting late in the disease course with significant irreversible joint damage may benefit from immunosuppression?
I think this is a very clinically relevant question. While I do not know of any study that specifically examines this question, studies suggest that tumor necrosis factor inhibitors may inhibit long-term radiographic progression and improve functional status. Long-term extension of secukinumab trial...
How do you approach the concept of spondyloarthritis disease activity "burning out" and no longer requiring immunosuppression?
This is a difficult question to discuss academically, as we will have to accept a definition for “burning out,” which may or may not be synonymous with remission or a state that will support drug-free remission. That being stated, the possibility of spondyloarthritis going into remission (no “inflam...
How do you rule out spontaneous bacterial peritonitis in a patient with minimal ascites that is not amenable to paracentesis?
You can’t, unfortunately. You either need to keep looking for a good pocket (move patient to each side, etc.) or use clinical judgement and decide whether or not to treat empirically.
Do you use buprenorphine in patients with chronic pain and prior history of opioid use disorder?
Absolutely. Buprenorphine is an excellent, evidence-based medication for patients with opioid use disorder, opioid use disorder with chronic pain, and chronic pain alone. The evidence in support of buprenorphine for pain has continued to accumulate over the past 10 years. At this point, I would neve...
How do you approach the management of patients who require nutritional restoration in the setting of a presumed functional GI disorder recalcitrant to behavioral medicine and pharmacologic therapies?
It certainly is a very good question if indeed the patient has functional disease; then, for sure, they need more than just my help. They probably need the help of a nutritionist, but even more so, they need perhaps psychiatric medication and the treatment of a behavioral therapist or psychological ...