Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
What is your preferred, first-line class of anti-anginals for MINOCA with proven epicardial coronary vasospasm?
We typically start with long-acting nitrates such as isosorbide mono or dinitrate, but often patients will have adverse effects to nitrates that make long-term use challenging. We have had good results with non-dihydropyridine calcium channel blockers, particularly diltiazem, both as short and long-...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
What is your approach to deprescribing gabapentinoids so as to prevent withdrawal effects?
Prescriptions for gabapentinoids are increasingly common, particularly for off-label indications such as neuropathic pain (1). There is relatively limited evidence to guide deprescribing strategies for gabapentinoids, as demonstrated in a 2023 scoping review (2). Abrupt discontinuation of gabapentin...
How do you approach revascularization in patients over 75 years with NSTEMI, given recent evidence from the SENIOR-RITA trial that an invasive strategy does not significantly reduce cardiovascular events compared to a conservative strategy?
The Senior-Rita trial was a randomized trial of nstemi patients over the age of 75 randomized to conservative therapy versus an invasive strategy plus optimal medical therapy. Non-fatal MI was more common in the conservative strategy group but overall a primary outcome event occurred in 25-26% in bo...
For outpatients undergoing a kidney biopsy, do you routinely recommend an overnight admission for continued hemoglobin monitoring?
If I perform an uneventful kidney biopsy in the morning on a patient with well-controlled BP and normal hemoglobin, I can observe the patient all day. If vitals are stable and the repeat hemoglobin at 8 hours is stable, I would discharge the patient. However, if I did the biopsy later in the day or ...
How to you approach the risk/benefit discussion for hormone replacement therapy in perimenopausal women with significant vasomotor symptoms and borderline ASCVD risk?
Thank you for this question. It is a conversation of a bit complex nature to be had with the patient. Generally, I follow the steps of [1] educating the patient on the data on the use of HRT in setting of ASCVD in that HRT is indicated for treating moderate to severe perimenopausal symptoms up to 5 ...
When do you consider using aspirin 81 mg PO BID for VTE prophylaxis over other agents in patients with a fracture, considering recent trial data?
Aspirin for VTE prophylaxis may be reasonable in selected low-risk patients, but many patients undergoing surgery for a fracture are at high risk for VTE. In addition to the METRC trial you cited, another relevant study informing my opinion on this is the CRISTAL trial.In METRC, the mean patient age...
How do you address social determinants of health that impact patients (e.g., housing instability, food insecurity) but for which there are no immediate resources available?
This is a complicated answer that will vary from state to state, county to county, and overall, it is not a straightforward answer. I do wish we had better systems in the U.S. for managing the social determinants of health (SDOH), and I don't have all of the answers here. Housing instability, food i...
For which rituximab infusion reaction symptoms do you consider it safe to re-challenge in the office with adjusted rates and pre-medications?
When deciding whether it is safe to re-challenge with rituximab after an infusion reaction, the most important consideration is the type of reaction that the patient experienced. This will help to risk stratify and determine whether same day or future infusions of RTX should be used. Importantly, th...
Do you routinely adjust your interpretation of SLUMS and/or MOCA tests in patients depending on their level of education?
I have routinely adjusted the MOCA score based on their educational level. If their educational level is less than 8th grade, I use MOCA Basic for assessment. Personally, I have not used SLUMS for assessment, so I cannot comment on that.