Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Is there any benefit to checking serum viscosity in patients with autoimmune disease and headaches/migraines to see if aspirin or clopidogrel may be beneficial?
The serum viscosity test measures the time required for the serum to flow through a calibrated capillary tube under controlled pressure. Clinically significant elevations in viscosity (≥2.5 centipoise, normal range 1.4 - 1.8 cP) can cause symptoms and are most commonly seen in hyperviscosity syndrom...
What is the interpretation of an IGRA with positive TB wells and negative nil and negative mitogen wells?
We don't see positive controls in most clinical assays. They are run, of course, but hidden from view. The mitogen well is the positive control in the IGRAs. The mitogen used QuantiFERON-TB Gold is, I believe, PHA or phytohemagglutinin. PHA turns on T-cells to indiscriminately. If I remember my mito...
Do you counsel a mother to avoid certain food in her diet if she is still breast feeding and her child has confirmed IgE mediated food allergies?
Wangberg et al., PMID 33636342 surveyed a total of 133 breastfeeding mothers with allergic children. A total of 47.4% of mothers reported their healthcare provider encouraged them to continue breastfeeding without dietary restrictions, 17.3% were advised to continue breastfeeding but avoid eating th...
Do you recommend the use of albumin-adjusted calcium measurement formulas to accurately assess calcium levels?
It is a reasonable approach to correct serum calcium using albumin when hypocalcemia is present, especially in a hospital setting. I believe it is less useful for evaluating hypercalcemia.Although it is reasonable to use albumin to correct serum calcium in patients with hypocalcemia it may be worthw...
What precautions should be taken when discharging a patient from the medical setting on new medication assisted therapy for alcohol use disorder?
Great question. This article absolutely adds to the argument for using medications for alcohol use disorder. The precautions would mostly explain side effects, just as you would for any new medication. A few specific considerations depend on the medication (I'll restrict this to four more common cho...
What recommendations do you have regarding the use of dronabinol to prevent cannabis withdrawal in an inpatient medical or psychiatric setting?
I routinely use dronabinol in patients who are heavy/daily cannabis users and are having a hard time as inpatients with any degree of withdrawal and cravings. It can be a good anxiolytic as well as antiemetic and orexigenic in this situation. Depending on their preferences, it can be scheduled with ...
How do you approach weaning patients off of buprenorphine?
I have found using injectable extended release buprenorphine (XR-BUP) as a good way to help patients taper off SL buprenorphine in a means much more tolerable than trying to taper SL buprenorphine. We published a case series on this approach (Ritvo et al., PMID 32925232) and subsequently another cas...
What factors influence your decision to start salt tablets, urea, or a vaptan first in the management of a patient diagnosed with SIADH?
In patients with SIADH, free water intake has to be less than the urinary electrolyte-free water clearance in order for the serum sodium level to increase, assuming no significant extra-renal fluid losses. Therefore, if urinary electrolyte-free water clearance is very low, then free fluid restrictio...
What is your approach to a positive PPD or IGRA in a patient with well-controlled HIV without significant TB risk factors?
I treat all HIV patients with positive screening tests. I consider HIV itself, regardless of CD4 count, to be the highest risk for reactivation disease. I believe there is data showing this risk to be higher even than organ transplant or cancer treatment patients. The problem, of course, is navigati...
During treatment of severe osteoporosis with PTH analogs (abaloparatide), would a rise in alkaline phosphatase level >200 (in the setting of normal GGT) warrant discontinuation of medication?
During treatment with PTH analogs, it is not recommended to monitor the alkaline phosphatase but only Vitamin D and calcium every three months. The alkaline phosphatase, of course, increases with PTH analog therapy, but there is no upper limit, and the concerns about osteosarcoma have been removed f...