Dr. Meredith Trubitt (1:41)

Sure, Moni. We are the Internal Medicine podcast. And as you already alluded to where we usually bring you expert interviews, we will not be doing that tonight. We will be the ones distilling down some of the plurals and you know, most updated clinical information from the conference so far and hope you guys enjoy the content like we did.

Dr. Moni Amin (2:01)

A reminder that this and most episodes will be available for CME credit for all healthcare professionals through VCU Health at curbsiders.vcuhealth.org and we're back. Like I said, we're in Nashville. And before we get started, I think it's Always good to start with some picks of the week. Caroline got some picks of the week for me. Or a pick of the week.

Dr. Caroline Coleman (2:22)

I've got a pick of the week. It is not Nashville related, but it is related to our trip here. And it also is an update since we were last meeting at 2025. It is a new candy on the block. We all know nerds gummy clusters, right? Like, we grew up with those. They made a resurgence, especially with athletes. Nom nom, nom, when they're going for a run. But now there is a nerds juicy cluster. And I relied on AI to give a description because I think it really summarized it well. So nerds juicy gummy clusters are roughly twice the size of original nerds Gummy clusters featuring a softer, more gummy forward texture with a juicy but not liquid strawberry punch center. So those have been our candy of the week so far.

Dr. Meredith Trubitt (3:03)

Yeah. We're unfortunately almost done with our bag. And it's only day one of the conference.

Dr. Caroline Coleman (3:07)

We will have to go on a search tonight.

Dr. Moni Amin (3:09)

Yeah, those are really good. I'm so glad that we are surviving on them right now.

Dr. Caroline Coleman (3:14)

Yeah.

Dr. Moni Amin (3:15)

Meredith, you got a pick of the week?

Dr. Meredith Trubitt (3:16)

I do. I'll go with our ugly bagel experience this morning, which was pretty good. But also, interestingly, it's in a quote arcade. So despite being in Nashville, felt like we were very much in the middle of Europe in the middle this morning, eating our ugly bagels, which were also not ugly.

Dr. Moni Amin (3:34)

They were actually very attractive bagels.

Dr. Meredith Trubitt (3:36)

Yeah. I have to say, perfectly round.

Dr. Moni Amin (3:38)

And then they also. I had a bagel sandwich with uggie sauce. Not ugly uggie. Just throwing it out there. I'm a fan. Okay. My pick of the week. Two of them. One that's very specific to Nashville and then one that's music. So Nashville, as you may or may not know, is known for its music and a lot of music history. People think about country music, but a lot of other great music has been made in the city of Nashville. And one of the highlight tours for me that I've done in the past, not this trip, is the RCA Studio B tour. It is great music history. You get to see the studios where they recorded some really cool stuff, and you get to see pictures of Dolly parton in her 20s. I mean, what else can you ask for? So highly recommend if you have. It's really not that long. I think it's about an hour. If you're a music history nerd, definitely do it. And then not historic at all. Is the new Harry Styles album and it is called Kiss all the time period, disco comma, occasionally. And I'll leave it there because it is so good and it's bringing me so much joy for the last like month. And with that we will start recapping to kind of get this recap started. Meredith, I was curious, what did you go to to start this morning? This morning?

Dr. Meredith Trubitt (4:54)

Well, I went with my best friend Richard, and we went to Bless yous Heart by our very own boss, Dustin Smith. A little bit on the updates and heart failure, were there anything in particular that you found most interesting?

Dr. Richard White (5:13)

Yes, I think one thing that we talked about was the role of thoracentesis in heart failure using the Tapit trial. This is a trial where they looked at doing thoracentesis in patients with heart failure. Three quarters of these patients had bilateral pleural effusions, which I thought was interesting. They looked at days alive outside the hospital in the next 90 days. Essentially big picture, no difference. So sort of confirming what I think we mostly do already is don't think about the synthesis in your patients with heart failure.

Dr. Meredith Trubitt (5:50)

Yeah, I agree. It was a good take home point. And there are a few things that were interesting about the trial too, which was like the complication rate for Thor as being 1%. So like which is pretty standard across the board, but just kind of reminding us that it's not a benign procedure either. And so for these patients that, you know, if diuresis and decongestion was going to work then to kind of stick with that. I was also curious what you thought about the sodium supplementation one. That one kind of. I don't think it's like quite practice changing yet, but it was a little bit mind blowing to me.

Dr. Richard White (6:26)

Yeah, I feel like this is one of those things that you hear about a lot using hypertonic saline to assist diuresis. And there's some physiologic mechanisms that do make sense. I've never done this before and I'm not sure I will ever do this at our hospital. So at any rate interesting. But yes, I think a little early for me to start using it.

Dr. Meredith Trubitt (6:46)

Yeah, essentially it's like suggesting. Well, it's like in this kind of very heterogeneous meta analysis showed improvement in creatinine. It's kind of a question whether that in and of itself is going to be enough to change management. And I think that the logistics of it, which you're referencing, which is that all these things for our hospital at least would be in like a ICU setting. It Just doesn't actually seem like a practical thing to do.

Dr. Moni Amin (7:11)

So was it just hypertonic saline and not like giving salt tabs or something

Dr. Meredith Trubitt (7:15)

crazy hypertonic saline, like 3.5% or 3% was the low end all the way up to 7 and a half percent, which I have never seen personally. And I don't know, like, I don't know who was making that if they're just like pumping salts like continuously into the saline bag.

Dr. Moni Amin (7:33)

For those of you not watching on YouTube, everybody's face during this part of the conversation has just been baffled and flabbergasted in all of the words and mind blown as Suchida is doing great.

Dr. Meredith Trubitt (7:45)

I did want to highlight one other one from that talk. So I think it was a few years ago for the strong HF study. So this strong HF and its initial review is really to promote us putting people on, you know, the four pillars of heart failure therapy. And when we've done our inpatient heart failure episode, this was really like a important, like highlighting point. And when we have all talked about it, we have all talked about it in the sense of, oh, well, who is the patient in front of you? It is someone who is often elderly or like, you're really worried about starting all of these medicines and being like, bye, you're going to do fine. And so we have often, I think on our episodes kind of cautioned a little bit into this like, realm. But they did a sub study analysis which Dr. Smith highlighted, which was looking at like high intensity up titration essentially very quickly and starting like going fast and high in these medications. And while that showed benefit, really the underlying thing that's showing benefit is the rate of decongestion and prioritizing decongestion. Thought it was a really nuanced way of describing those studies and what they're doing, which I think when we've talked about in the past, it's just like, ah, guidelines, four pillars of medications do it all. But I think kind of highlighting that nuance of the decongestion part I think is really important. And when we did the inpatient episode with Dr. Pandroth, that was something he also like highlighted multiple times in that like how important, just like decongestion is. And so I just thought it was

Dr. Moni Amin (9:29)

worth noting here too, things that people kind of, we, I think we had all sort of in the back of our minds thought about that and it kind of has come to fruition with further study.

Dr. Meredith Trubitt (9:38)

Yeah.

Dr. Moni Amin (9:39)

As we've been at shm.

Dr. Caroline Coleman (9:41)

Yeah. Cool.

Dr. Meredith Trubitt (9:42)

Do you have any Other ones you wanted to highlight or are you good?

Dr. Richard White (9:45)

I'm good.

Dr. Moni Amin (9:46)

Great. Caroline, what did you go to this morning?

Dr. Caroline Coleman (9:51)

I went to top 10 of things we do for no reason. It is the 10 year anniversary of something that we end up talking about every time we do this recap episode. But they went through their top and not top 10 articles that they have written in the last 10 years and they've published over 120 articles, which is just amazing. And I think it's such a favorite teaching tool of a lot of us that work with trainees. So it's really neat to look back and reflect on how many topics they've covered. But they spent the majority of the talk focusing on four things that maybe are not the newest articles they've written, but the things they think we really need to continue changing our practice around. And I know Dr. Hunt went to this talk as well. Do you have a favorite article that they spoke about?

Dr. Dan Hunt (10:37)

Oh, I'd had several favorites. So my favorite actually was the thinking about cellulitis, simple cellulitis, which is typically strep. And looking at do we need to use advanced coverage for patients? So we overuse vancomycin. We underutilized simple first generation cephalosporins or clindamycin in a patient who has allergy. And I thought that was a really compelling thing, although it goes back a long ways. I can remember when we actually tried to culture the lead edge of cellulitis, which they mentioned in their talk. I never saw a positive. And then they went on to think about the patients who need more advanced treatment, Vancouver, and the patient who has an abscess. And thinking about what's the utility of MRSA swabs in the nose, which markedly reduces the likelihood of MRSA in that abscess. So I thought it was a great talk.

Dr. Caroline Coleman (11:40)

Absolutely. And they covered a couple of different organ systems as well. They also went on to talk about deescalating, dual antithrombotic therapy, unstable coronary artery disease, anticoagulation and falls. Any other pearls that you picked out from this?

Dr. Dan Hunt (11:57)

I love both of those. Yeah. Because for a long time I've thought fall should not be a contraindication to the use of anticoagulation. And it was pretty clear cut with a Pixaban. Very safe. The number of patients we would need to treat was into the hundreds of falls before you would see an adverse intracranial bleed. So I think that's practice changing, reminding us about that. And then I thought the comments about DOACs and antiplatelet agents in patients with stable coronary disease and atrial fib. So the patient who is six to 12 months out from a PCI, we could be taking them off antiplatelet agents and continuing apixaban alone, which is practice changing.

Dr. Caroline Coleman (12:44)

Absolutely. And something that I think is often within our wheelhouse as hospitalists. We'll notice that on the med rec and his an action that we can take when we all return to work next week.

Dr. Dan Hunt (12:54)

Now, I will say something else about that, and it wasn't really covered, which is we need to contact the primary care doc because you can imagine what happens when you send that patient back to primary care. And I did primary care for a long time now the patient comes back to me and I say, why did they stop that agent? And that needs to be very clear cut in our communications.

Dr. Caroline Coleman (13:17)

Absolutely. And the crown jewel of the talk talking about treating asymptomatic hypertension in a hospital.

Dr. Dan Hunt (13:25)

Oh, I love that one.

Dr. Caroline Coleman (13:26)

Take it, take it away.

Dr. Dan Hunt (13:28)

Just don't

Dr. Moni Amin (13:30)

like drop, say less

Dr. Dan Hunt (13:33)

so. And I think that Tony Brugg did a nice job of thinking about the pathophysiology here and thinking about if you are treating acutely, you are saying, I'm going to reduce the incidence of stroke in the next four to six hours, which is just irrational. So there may be limits to what we should tolerate in terms of blood pressure in the hospital, but it's dependent on are there other consequences of the blood pressure elevation that we should be worried about? So the true accelerated hypertension or emergent state?

Dr. Caroline Coleman (14:07)

Absolutely. Moni, what kind of talks did you go to today?

Dr. Moni Amin (14:10)

Yeah, so I did updates in pneumonia, which every time I go I'm like, oh, wow, there have been updates, which is, you know, kind of speaks to how little I think about pneumonia, except when I'm training it, I guess. But one of the things that I remember not well from training was kind of the conversation about steroids. And honestly, we haven't really gotten a lot of clarity in the time I went spent training. And now there were two studies that they talked about for this. The Cape Cod study from, I want to say I can't remember exactly which year actually, but this was like ICU patients with severe CAP and they got IV hydrocortisone and they thought that there was a lower risk of mortality. But then fast forward to the REMAP CAP study. Love these names. Hydrocortisone was not likely to yield improvement in mortality. So I think it's still out there whether or not we should be doing steroids. I thought one of the most important things that I needed to be better about myself in practice that I learned today was it's really okay to rapidly transition to orals in a lot of. In some patients. These are patients that have clinically improved as defined by no fever, not tachycardic, not tachypneic, not needing oxygen, with a systolic greater than 90 and normal mental status. So that's a lot of criteria to meet. But you do have a few patients that do improve within three days and if they do, that might be sufficient and you may not have to discharge them home with antibiotics, which is truly mind blowing to me. Like when my residents ask me, I feel a little skittish being like, no, don't send them home with anything, it'll be fine. And actually it might be if they really did improve within that three day frame, certainly five days would be sufficient in a lot of cases. So that was really helpful. And then my favorite part of the talk actually was the. This has been like the week of debates between different decision making societies. And the speaker, one of the speakers, Dr. Valerie Vaughn, who's out at Utah, she's on the committee that makes decisions about. I can't remember if it was ATS or idsa, but the two societies had a bit of a falling out over the decision to whether or not you should give antibiotics and viral infections. So ATS felt that if someone has enough, sufficient comorbidities, it's reasonable to give antibiotics and viral infections. IDSA said no empiric antibiotics unless you're suspicious of a CO infection. Now, I think it's kind of hard sometimes to know if you're suspicious of a CO infection. So that's kind of a weird. Not weird, but that definitely makes it challenging to know whether or not you should. I think most of us generally in viral situations, if someone is not clinically improving, then you start thinking, okay, maybe I do need to think about bacterial. But I think to start, most of us kind of hold off. And these recommendations made me think that's probably a reasonable place to start at all. Unless you really do have a really strong suspicion. But yeah, those are kind of the big things. Steroids still up for debate. Antibiotics probably don't need to give very much, a lot less than we used to think. In fact, one of the things I found interesting going back to that was as early as the 1940s did they have studies where it was like two and a half days of antibiotics and then they stopped in pneumococcal infections. And it seemed to be okay. So we've known it for a while and we just kind of backtracked a little bit. So.

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Dr. Dan Hunt (19:27)

Foreign

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Dr. Moni Amin (21:14)

Meredith Any other pearls from this morning?

Dr. Meredith Trubitt (21:18)

I went to the pharmacotherapy talk, which was a nice talk given that both speakers in a previous life are pharmds and now both hospitalists. I mean really they talked, they covered a lot of ground. But I'm going to kind of just talk about two the first is some information on phenuro known which was also brought up in Dustin's talk. But I think this is going to be kind of the hot thing coming down for heart failure going forward, really showing in some of the more recent like sub study analysis too, pretty good efficacy in reducing worsening heart failure within kind of the like at time of hospitalization to like kind of up to three months. Again kind of looking at some of the decongestion and other parameters and there's going to be some new studies coming down the pike to both redefine and confirmation which should give us a little bit more information about that one too. So both talks talked about that. And then the other one that I wanted to mention that I think is just a little bit hot off the presses too is we talked a little bit about lipid management. They also made the joke that that's not what most hospitalists are thinking about.

Dr. Moni Amin (22:33)

No.

Dr. Meredith Trubitt (22:34)

But the new lipid guideline just came out in the last month. So that's why I say hot off the presses. And I also wanted to bring it up because actually this came up for my team recently too. So I think we all take care of enough patients with cardiovascular disease one way or the other. And we and I don't know what everyone else's practice at this table is, but mine is very much like is that statin at a high intensity refer to outpatient otherwise. Um, but you know the guidelines that just came out. They had outlined them and do give pretty clear guidance on kind of what would be your escalation pathways, including, you know, PCSK9s in glycerin and the bempedoic acid. Um, and all of these were like, new things to me, but kind of the hot take and some things to think about are probably early initiation of the PSK9s because our lipid goals are lower than they've been before. Um, and so not just kind of stopping at the statin therapies. And then the other thing is, I think there's going to be, like, more information that comes out as some of these other studies come out. But the interesting thing to me is I also don't know who at this table has dealt with this, but probably everyone, like, statins and people are like, I can't be on a statin. It caused me so much pain. And like, how dare that happen? And while the current guidance is really that the bempedoic acid is going to kind of be your last line, because it's just not quite as efficacious, it is an oral option, and it's acting like, upstream of where the statins act. And so it gives less myalgias and, like, adverse events for that. So I think, like, I can see that in the future kind of becoming, like a little bit of an adjustment as we think about this for some of our patients and where to kind of escalate care. And I think that is where I will leave that one. I think we should do maybe liver.

Dr. Moni Amin (24:32)

Yes. That was a highly attended session from our recap group, and I wanted to bring in returning guest. Actually a throwback to our very first episode we ever did at SHM, Dr. Suchita SATA from Duke. So glad to have her back. And it's fitting. We talked to her about the liver then, and she is talking to us about the liver again. And I know that Richard also went. And for those of you that may not know, Dr. Richard White is one of our colleagues at the VA in Atlanta, and Dr. Dan Hunt is actually our boss, the Division of Hospital Medicine director for all of Emory. So we're so glad to have all of them. And I want to make sure we did brief intros for all those voices that you just heard. I'm going to turn it over to Suchida and Richard to talk a little bit about the great liver talk that we all went to.

Dr. Suchita Sada (25:15)

Thanks so much, Moni. And if I may, I could say, gee, I love the liver, but today I went to a talk by Dr. Tony Brew on severe acute liver injury and thinking about the approach to diagnosis and initial evaluation. And I think that Tony made a really great stand up. First point, acute liver injury is different from acute liver failure. And so these are the patients who are coming in with an AST, ALT elevation, a T Billy elevation, an INR elevation, possibly, but not with any hepatic encephalopathy or confusion. So I thought that was a really important distinction clinically. And the patients who are really sick should get to a transplant center asap. I think one thing that I really took away up front was I love how Tony broke it up into like, here are the big four reasons that people develop acute liver injury. And I think we all think about like, hey, ast, ALT are in the thousands. Let's think about shock liver or the ischemic hepatitis. Do we have a bud Chiari or hepatic vein clot? Let's look for that. But then the other ones are second most common. The drug induced liver injury, particularly acetaminophen, is the most common reason for acute liver injury other than hepatitis. Viral hepatitis in some patients is what I learned from Tony. And then viral hepatitis and not just, as Tony put it, A, B and C. So hepatitis A, B and C, but some of the less common ones that we aren't usually testing for, like cmv, EBV, and in particular hsv because that's the one that can cause like a fulminant liver failure.

Dr. Moni Amin (26:59)

But we have a treatment for it.

Dr. Suchita Sada (27:01)

So if we aren't searching for HSV hepatitis, then are we missing the opportunity to treat these patients with acyclovir upfront and potentially improve their outcomes? And then the last one of biliary obstruction causes for acute liver injury. So that was one of my first takeaways.

Dr. Richard White (27:20)

Yeah. And I think going from those four big causes of severe acute liver injury, we talked then about your phase one workup for severe acute liver injury, which is really informed by those causes. First, get a good history, which hopefully we're all doing. Get an acetaminophen level and then get your viral serologies included. Hepatitis A, hepatitis B, hepatitis C, but also EBV, CMV, both IGMs and HSV like we talked about, which can cause a fulminant hepatitis. An ultrasound with Doppler, given the ischemic hepatitis risk. And then he added a ck, which is not one of the most common causes but would be an embarrassing thing to Ms. Rhabdomyolysis when you're talking about elevated ASDNA LT yeah, and I just.

Dr. Moni Amin (28:05)

We do a lot of liver on curbsiders, so if. If you're at all, like, wanting more details, there's multiple Elliot Tapper episodes about liver stuff. And one of the things that Tony brought up during this talk was the things we do for no reason about the hemochromatosis alpha 1 antitrypsin and primary biliary cirrhosis workup. It's a don't do it. You don't need to do it. And specifically, I think one of the things I forget often but shouldn't is iron elevations are a consequence of liver injury and not a cause. So he had examples of patients that he had taken care of, and they had gotten iron studies both before and after, and the ferritin was sky high. And, like, all the other things were sky high in the acute phase. Only reiterating like, this is clearly acute phase, and do not use this as a reason to do all these other tests that you actually don't need. Richard Suchita, do you have anything else you wanted to bring up?

Dr. Suchita Sada (29:03)

Yeah, Moni, I think I've fallen into that trap before myself, particularly in patients who are coming in. I'm like, oh, right, they're anemic. I'm gonna evaluate their anemia, I'm gonna check their iron studies, and then it comes back with a TSAT percentage of like, 100. I'm like, oh, man, what am I gonna do with this number? So I think that was a really good teaching point that Tony brought up for this conversation of in acute liver injury, the ferritin, the tibc, the transferrinsat are not gonna really help us understand causes or even our anemia workup in that acute state. One thing that I really liked, and I will take away my teaching, is thinking about, like, the alt, AST half lives and why one of them is dropping faster. The AST half life is half of the ALT half life. So in the acute liver injury, the ALT is gonna stay elevated for a little bit longer, but it's not necessarily a marker of the ongoing liver injury. So I thought that was a really fun pearl that you can impress all your learners on when you bring it up on rounds.

Dr. Richard White (30:15)

Yeah, 100%. And a couple other quick pearls I took from this just thinking about the degree of enzyme elevation. More than 10,000. Almost always ischemic or dili from acetaminophen. And when thinking about alcohol associated hepatitis, an AST or ALT above 400 effectively rules that out. So if you're seeing more significant elevations, think less about alcohol Associated hepatitis.

Dr. Moni Amin (30:39)

Great. Yeah. There are so many pearls in that. And like I said, we have a lot of curb episodes dedicated to the liver. So just seek them out if you want more details on any of the stuff we just went through. But it was a really good recap of all the things that he went over and probably some of our older episodes. Meredith, any other pearls from something you went to in the afternoon?

Dr. Meredith Trubitt (31:00)

Well, Caroline and I both went to a nephrology one. And not to throw shade or anything, but we were, we had low expectations because we were like, what has changed for kidney management? Like I thought, it's all pre renal, it's all fluids. That's all there is to it. Sometimes you need a Foley, but the speaker did a really good job at highlighting some really good take home points. Actually had 16 take home points, which when he started with that, I was like, where are these 16 coming from? But they're all really unique and helpful. So were there ones that stuck out to you that you want to start with?

Dr. Caroline Coleman (31:37)

I do have 16, but I'll narrow it down to a couple. And the first is something I feel like I see every time on service is a patient that comes in with the aki and you're figured out what's causing it and their creatinine's down, trending. But do you really need to get back to their true baseline or are they ever really going to get back to their true baseline? So he introduced a term that was new to me called acute kidney disease. I know we're all familiar with chronic kidney disease, but it's this entity where in a patient that develops an aki, they may not return to their normal renal function for up to 90 days. And that about 25% of patients who develop akis are going to develop this entity, acute kidney disease, and take 90 days to get back to baseline. So I think this will make me feel more comfortable when I've given my patient plenty of fluids. Their creatinine is 1.2. Maybe not totally back to a normal baseline, but maybe feel more comfortable with discharging them with a slightly elevated creatinine. Still knowing that this is going to take more than just two or three more days of hospitalization and just really needs good primary care follow up. So that was groundbreaking for me. What about you, Meredith?

Dr. Meredith Trubitt (32:42)

Yeah, so I think the one that there's kind of two that are unrelated but sort of related. So he first talked a little bit about furosemide stress testing. So when someone comes in really like severe aki and you're trying to assess, you know, what is the likelihood that this person is going to progress to dialysis, going ahead and doing the furosemide stress test. If they have urine output over 200ml over the first two hours after furosemide, it's predictive for, like, who is less likely to essentially progress to needing dialysis. So it can give you kind of useful information because that's really what your patient is actually asking for in that moment. So he said that's actually something he does on, like as part of his everyday practice. And then the other one that I do think comes up a lot is a little bit about the sulfa allergy with furosemide. And kind of the interplay with that I don't like, typically when we are staring at molecules. But what he did identify is that the molecular structure of furosemide is quite different actually than your sulfa antibiotics. And people who have a sulfa allergy are just more likely to be allergic to medications. It is not predictive necessarily of them being more sensitive to the furosemide itself and should not be a barrier for them getting furosemide. So even though I think every EMR will probably put a stopgap for you, it should not be concerning in the way that the AMR is telling you and flashing red lights to stop.

Dr. Caroline Coleman (34:25)

We spent a lot of time talking about Akis and the medications we use to treat it, but we did pivot to hyponatremia as well. And I think I have a pretty standard lab workup that I order when someone comes in with hyponatremia serum OSM. And he mentioned TSH as well. And he mentioned some older studies, 1997, that showed that only incredibly large derangements in thyroid function are going to cause inpatient hyponatremia. And he put up a study that was showing that even with patients with TSHS as high as 40, 60, 80 were not having derangements in their inpatient sodium. So it takes a very extreme thyroid derangement to cause hyponatremia. And I think I order it all the time, and maybe I'll expect to see that be a cause of hyponatremia less Great.

Dr. Moni Amin (35:17)

I think, Dan, you went to the medted teaching competition, which was in its first year last year, is that second year. It has become a highlight of the conference every year. And I think you had some pearls from the winner.

Dr. Dan Hunt (35:34)

Actually, I did.

Dr. Moni Amin (35:36)

Please share them.

Dr. Dan Hunt (35:37)

So seven great talks. And the winner actually talked about CAR T and bite causing cytokine release syndrome. Anybody know what BITE is?

Dr. Moni Amin (35:49)

No. Please explain.

Dr. Dan Hunt (35:51)

Bispecific T cell engager molecules that tie a T cell to a cancer cell. And they have all kinds of names. I can't remember those. The speaker actually said didn't recognize some of the names when she first started as an oncology hospitalist. But we need to recognize that these would be patients who would present as if they have sepsis. Six to 12 hours after the infusion of bite fever, tachycardia may progress to shock. And your temptation is going to be to say, this is sepsis. I'm going to treat it as sepsis. In fact, if the patient is immunocompetent, doesn't have neutropenia, doesn't have leukemia, doesn't have conditions that we typically would associate with immunosuppression, that patient should be treated with tocilizumab or steroids. Really cool teaching points.

Dr. Moni Amin (36:53)

Yeah. And I had you talk about it because I knew you'd done that, because it kind of dovetails really nicely into this fevers in ONC talk that I went to, because it did mention that. But what I really liked about this talk was that there was a framework that they provided to think through patients that have cancer and then come in with fever. And the framework was helpful because I think a lot of times you just kind of shotgun everything and not really have a systematic approach to it. And so the framework that they provided was to think about host factors, and under that, the subcategory of what's their immune system doing, what's their reserve, so their performance status and exposures. So hospitalizations, prior MDROs, recent antibiotics, things like that. So host factors, the first, the second would be their anatomy, Barrier integrity loss, obstruction or implanted devices. So anything that is wrong with their anatomy, and then three is their cancer treatment. So thinking about their checkpoint inhibitors or their immune effector therapies. Which is what you're referring to, Dan.

Dr. Dan Hunt (38:00)

Correct.

Dr. Moni Amin (38:02)

Which causes this, like, storm of stuff.

Dr. Dan Hunt (38:05)

And another point that the speaker made that I think is really important is do not hesitate as a hospitalist to wake up the hematology or oncology attending at 2am if you're worried about cytokine release syndrome. Because we need help for sure.

Dr. Moni Amin (38:18)

And I'm not sure I would feel comfortable pulling the trigger on tocilizumab without someone else telling me that was a good plan.

Dr. Dan Hunt (38:23)

Well, I'd have to get approval from somebody

Dr. Moni Amin (38:27)

at our site. We'd probably have to wake up a pharmacist. To get that one through in the middle of the night.

Dr. Meredith Trubitt (38:31)

Yeah. Do you really want to get into who we would have to call here?

Dr. Moni Amin (38:34)

Nope. So that I kind of wanted to interweave your learning points from the teaching competition and then the fevers and ONC talk, which had a really good framework and potentially could be an episode first on the line. So I don't want to get too far into the nitty gritty of it. So I wanted to keep it moving with other talks that people went to. Meredith, I think you went to one on alcohol withdrawal.

Dr. Meredith Trubitt (38:55)

Close. It was a addiction best of addiction for really what hospitalists need to know.

Dr. Caroline Coleman (39:01)

They too.

Dr. Meredith Trubitt (39:02)

I don't know if this is a theme this year, but hit on like 10 different high yield points. But I mean, kind of distill it down one. I'll just shout out. Our addiction medicine team from Curb have really great episodes on each of the specific syndromes and kind of different settings. You may take care of them. But my humanism in medicine and addiction medicine are in crossover into the beginning of their talk. So they spent the beginning really talking about stigmatizing language and how much it impacts our ability to care for these patients. And that it really starts in the emr, including language that we all have heard many times, but, you know, drug seeking, not using like patient first language, you know, questions about pain management. All of these things that sneak into the EMR and cloud our judgment into being able to take care of these patients well. And the more that that stigmatizing language is present in the emr, the more it impacts our ability to care for the patients. It increases things like patient directed discharges. All of the other things that we are trying to, you know, stop essentially so that we can actually treat these patients well. And it goes all the way up, if you kind of think about it, into a model format leading into like hospital polic. They also talked about, like, if your policy, if you have a patient. And this has happened to me many a times, that is. I know it's happened to you too, because we have shared a story. But catching them with, you know, drugs or paraphernalia and kind of what is the purpose of security searching them. We have patients who bring in outside meds all the time. And you don't bring a security guard in to search all of their belongings after that. You just kind of say, hey, we don't do that. This is because we are trying to do this respect that you are trying to take your medications and talking to them in that way. But many of us have policies and things in place that make us feel that we need to act this way. And so kind of thinking about, hey, what are our hospital policies? Are there ways that we can make this less punitive to this population to make sure that they are able to seek care in a safe environment as well. So I just wanted to shout out that part of it because I think that's really important to just be framing like our work with our colleagues, because it starts with us. If you buy into that, which I

Dr. Moni Amin (41:23)

clearly do, I just let. I like hearing you cook. Like we just let you cook on those things and you always nail it. So keep going.

Dr. Meredith Trubitt (41:30)

They also talked a lot about when you are at the stage of, you know, starting medication therapies for opioid use disorder. Some of the changes that like with methadone and buprenorphine we have to think about in the fentanyl era, that methadone is actually a quite rapid up titration over just a few days in buprenorphine, oftentimes because of their requirements with fentanyl actually going to do like a short acting opioid to make sure that they are getting enough mu opioid action as you're adding in like the lower dose. Bup. But I liked the way that one of the speakers described explaining it to their patients, which is like pretend you have a bus full of football players getting to the football game and instead of all the football players coming off at the same time and the cheerleaders getting on after that, cheerleaders being buprenorphine, you're going to replace them one at a time so that you will suddenly have a bus of football players transition to being a bus full of cheerleaders. But you won't feel the difference. It won't be a sudden change that happens all at once. So I thought with each seat kind of being your receptor, you could get into all the details of that with the patient if they needed to. But it was kind of a nice visualization and that also I won't talk too much about it because I just don't know that we have a ton of time, but also touched a little bit into drug supply contaminants with xylazine and metadomidine. I can never say it, but really that those two as contaminants. I know some of us know xylazine for like the wound problems afterwards, but also that both of them can cause pretty significant autonomic instability in the days after admission. So these are the patients that you have started on like your Medication assisted therapies. And now all of a sudden you go in and see them and they're like, I feel funny. I'm like, a little tachycardic and a little, like, hypotensive, but feel like my opioid use, like, withdrawal syndrome. They're actually probably having some of those autonomic instability. And some of those patients do need to go to, like, the ICU for like, a prosth strip or whatever for that time that those contaminants are coming out of their system. So I thought all of those were really good highlights. And the last thing I will just highlight is for stimulant use disorder, which they did kind of as bonus material, I think, because for stimulants we're like, oh, there's no FDA med. There's nothing I can do. Like, peace. Good luck to you. There is some, like, promising studies coming out on, like, outpatient, like, reward systems for creating, like, positive behaviors for, like, negative uds for the patient and really searching for kind of where patients can get that as an outpatient therapy. It's not something that we can really initiate on the inpatient side, but thought all of that was great.

Dr. Moni Amin (44:25)

I think the culture has changed significantly from the time I was training to now, but still a lot of work to do in sort of the stigmatizing language in that space. I think that's something that I think actually a lot of us that work together talk a lot about in the chart. I know I've had conversations with you, Richard, about sort of the language that we put, even about things about disposition. We'll kind of keep it moving with our recap. We have some new voices that you're about to hear. Dr. Kirsten Kennedy out at UAB and Dr. Noble Molek, who was our lot of returners today. So Noble Malik was our very first hospital medicine guest ever for inpatient hypertension management, and so happy to have him back. Just a party and a half. Always with Noble. Maybe he has puns today. I don't know. We didn't ask ahead of time, so we'll. We'll see. It's always a party.

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Dr. Moni Amin (46:38)

I think we'll start with a little bit of an ID potpourri if you will, because both Caroline and I attended some sessions that were in the ID space and so Caroline, why don't you start us off.

Dr. Caroline Coleman (46:51)

So many germs were discussed, but I think my favorite update was the new 2025 IDSA guidelines on complicated UTI came out last summer. So nuisance SHM last year and like is the trend in a lot of antibiotics. We are encouraged to deescalate stable patients from IV to oral if they are, you know, the central tenets to all this de escalation, clinically improving, able to take oral medications and an effective oral is available. But they mentioned that fluoroquinolones and Bactrim are still going to be our preferred agents, whereas cephalosporins have a lower bioavailability, lower urine concentration or less preferred. And I was just, it was bouncing around in my head, I was like, why does this sound backwards? And I think it's helpful to compare this to CAP oral deescalation, which is reversed. So even if that urine susceptibility comes back on your complicated UTI and says, oh, you're susceptible to a MOX Clav or an oral cephalosporin, you still want to go for our fluoroquinoline Synbactrim inverse of what you would do with cap. So I think that was a good framework for me to go back home and realize, you know, in these patients I might be managing without an infectious disease consultant to remember that even if the susceptibility says that's a good drug, remember that the cephalosporins don't concentrate in the urine and are second line.

Dr. Moni Amin (48:14)

Yeah, I feel like I don't remember that well enough.

Dr. Caroline Coleman (48:17)

I did not remember that last week when I was on service. So that was. That was a personal note for me.

Dr. Moni Amin (48:22)

Yeah, great. What other nuggets did you pick up?

Dr. Caroline Coleman (48:25)

We also went through some susceptibility and resistant organisms and back when I was in training we had the space and the spice organisms that had inducible amp C production. But there's a new kid on the block and apparently it is just EK which is going to be Enterobacter cloacae, Klebsiella erogenes, formally Enterobacter orogenes and Citrobacter frundi. Apologies for butchering those to the germs, but that's going to be ECK for our new acronym for inducible amp C organisms. And it's not as catchy as space or spice, but the speaker did say, you know, we've got to stop trying to make ECK happen. It's not as good as fetch, but I think I can remember that one to go home with.

Dr. Moni Amin (49:12)

Well, it was accompanied with a mean girl slide if I do recall.

Dr. Caroline Coleman (49:15)

It was just Regina George's face.

Dr. Moni Amin (49:17)

Just fantastic. I can't even imagine being in a room with a slide like that. Just very exciting. Not as good as Britney Spears yesterday, but close. She's very close.

Dr. Caroline Coleman (49:27)

I know you heard some talks about Daubava Vanson characters.

Dr. Moni Amin (49:30)

I did. So I went to I just all the Nashville themed titles this year. Super fun Nashville Hot where Back to Remy brings the heat. Great ID and hospitalist and one human. Allison Bond from ECSF gave a great talk today. She had a couple things, the biggest takeaways for me and what she wanted me to take away too which is nice when that sort of goes together in gram negative rod bacteremia 7 versus 14 days. Honestly, 7 days is fine. They're not inferior and it's totally okay. Strep bacteremia PO vs IV. The only difference between the patients that got IV vs PO is the PO patients had shorter hospital stays, which we all know is the goal. So that was great. And then kind of circling back to staff Aureus and some of these questions. So they had a few take home points for that section. One that I don't think any of us here like at least where I practice was never really on my radar anyway that like apparently people get routine pet CTs on patients that have staph aureus bacteremia. Did not know that was a thing but you shouldn't be doing it was one of our take homes. So great. I'm glad I Wasn't doing it. And then the other thing speaking to Dalbovansen, it took me a minute to get back there. Caroline. Both that and then Cefto Biprol. Hope I said that right. Are suitable alternatives to conserve our current standard of care. Antibiotics for staph aureus. Bacteremia. So I feel like we use a lot, at least where we practice. I have seen Dalbavansen probably more than I would have expected. And that kind of tracks with our this talk.

Dr. Meredith Trubitt (51:14)

Noble. You want to correct the pronunciation

Dr. Moni Amin (51:19)

again, for those of you that don't watch the YouTubes, I was getting a lot of wonderful looks as I was stumbling through that pronunciation.

Dr. Caroline Coleman (51:26)

Nobody stepped in to help you?

Dr. Moni Amin (51:28)

No. But that's kind of my life. So. And then the last take home I wanted to highlight from this awesome talk was seven days of antibiotics is enough for most uncomplicated bacteremia. That's not staph aureus or longinesis. And that is from the balance trial that was published in the Lancet. For those of you that want to go back and read that article, which I just found to be great because I know that one of our biggest challenges in a lot of our patient populations that are underserved don't have health care access very well, the PO and IV stuff really comes into play for disposition planning and stuff like that. And so to see that the data is supporting things that help us take care of our patients better is really nice. Any other ID potpourri? Caroline? Before we move out of that space,

Dr. Caroline Coleman (52:14)

just another point on the Dalba Vansen. A couple speakers mentioned it for scan and soft tissue infections, and that is the only FDA approval. There are some promising trials, like the DOTS trial last year about the staphylorheus bacteremia, but I was not aware that Dalavansin is anywhere from three to six thousand dollars for a complete course. You have to weigh that with if you're getting the patient out of the hospital two or three days earlier. Is there a cost saving that's going to offset that high cost? But I had no idea it was so expensive. So that will be part of my decision making moving forward.

Dr. Moni Amin (52:47)

Yeah. And I do want to make sure I don't misrepresent what the speaker said about Dalbovansen at our talk. She said very specifically, it's not like wouldn't recommend it for every patient. Everything is case by case. So I just wanted to reiterate that that was not like a blanket recommendation she was making and don't want to misrepresent what she was saying.

Dr. Caroline Coleman (53:05)

So my speakers also made that nuanced. You know, select patients make this in decision and consultation with id, but select people do, you know, do really well on this.

Dr. Moni Amin (53:14)

Yeah. So maybe it's just something that for us to know that we can ask ID sometimes. All right, so I think we've had enough of the bugs, the germs. I'd like to move over to. I think Meredith and Noble had some fun today with the clinical guidelines updates. Maybe not. I don't know.

Dr. Meredith Trubitt (53:33)

Yeah. So we both were at the clinical updates today. And I know there will be more that we'll get to this afternoon after the big plenary for updates in hospital medicine. But what were kind of some of the your early take homes from it?

Dr. Noble Molek (53:47)

I was really interested in transfusions. And speaking of parties and natural, the American association of Blood bank, those are party people and they put some guidelines out about transfusions in myocardial infarctions and stem type 1, type 4. And I think we've all have this number of seven just cemented in our brain as a threshold for transfusion. But the recommendation was to transfuse to 10 for people who are undergoing who have MI or ACS. They did recognize it was low certainty evidence. And I think one thing I really enjoyed that the speaker said was you might think people may be out of their lane with this whole MI thing. But they said, one, make sure you see the patient and don't give them like three units of blood for people who might be having like heart failure or problems with their mi, which I think that was really good. But they also mentioned the ACC guidelines for a separate issue, but they also recommended a level of 10. So they were, I think, in line with their cardiologist too.

Dr. Meredith Trubitt (54:48)

Yeah. And the other thing he highlighted that I found helpful was he was like, it is all mis. So stemi and stemi, type one, type two, type four. He's like, all of it is included, which I think often comes up as a question. Being like this somehow seems like a lesser mi. Should I be as aggressive with this transfusion protocol? But it was really for all of them. So I found that really helpful. Helpful also talked about platelets, and I think that's when everyone made some gaffes in the audience for LPs specifically. So I know previous procedural list over here, sort of maybe current, but they talked about the LP recommendation. So do you want to share with everyone kind of what the magic numbers are now?

Dr. Noble Molek (55:32)

Yeah, I think just in general, they were talking about patients who are maybe at risk for having low platelets, people who've had stem cell transplants or cancer. And then I think they still have the same kind of threshold for the less than 10 for people who are asymptomatic just to have that marker. But for LPs, because in my mind I had 50,000 in my mind for LPs and the guidelines also from the American association of blood bank was 20,000, which.

Dr. Moni Amin (55:58)

Gasp.

Dr. Noble Molek (56:00)

Thank you. I think that if I was one doing the LP, they would really want to have 50,000 pilates.

Dr. Meredith Trubitt (56:05)

Yeah. I also they compared that to then the IR proceduralist guidelines, which were not quite as like they were the same, but it seemed like for the other procedures they were a little bit more conservative.

Dr. Noble Molek (56:22)

My recollection for the IR procedures, for things like paracentesis and thoracentesis and maybe fine needle aspirations, they still have the guideline of 20,000, but for maybe more deep tissue biopsies, anything with a sheath, they recommended 50,000, which I think is more in line with what we think about.

Dr. Meredith Trubitt (56:41)

And I just found it notable because I can see at my cash lac, everything's going to get labeled as high risk with interventional radiology and it's not going to go into the details of that. So I do anticipate there will be a future consensus statement. Could lead to a things we do for no reason kind of situation. I don't know, tossing around some ideas.

Dr. Moni Amin (57:04)

Yeah, I'm going to ignore those ideas at this moment because my brain is fried, but we'll keep that on the back burner. That's mind blowing to me though. I would have so much anxiety. But, you know, if there's guidelines, that's reassuring.

Dr. Meredith Trubitt (57:16)

Yeah. Essentially the. They said the risk for like the bleeding events are quite low and so they've readjusted like the platelet transfusion thresholds,

Dr. Noble Molek (57:28)

which I found interesting because we think about the blood bank being, you would think, conservative and wanted to be less items, which is why it makes sense to me that they would do 20,000, which is why I was also so surprised about the 10 hemoglobin for mis, because it's also a resource. So I thought that was really interesting.

Dr. Meredith Trubitt (57:45)

Yeah. Okay. I think the only other part that I was going to highlight too was we talked about it yesterday from the nephrology session, but they did kind of say, kind of keep our eyes out because this, the overcorrection of sodium in the like New England Journal article and some of the critical care in the Journal of Critical Care have kind of done away with this overcorrection of sodium. But there's other articles from like kidney, I think it was kidney medicine had one student say, hold your, hold your horses a little bit. And we kind of referenced this in this nephrology talk yesterday and they said, just really keep an eye on it. It's looking like there is probably low likelihoods or like just a low percentage of patients that experience the demyelinating syndrome, but it's also something we just don't want to have happen either. And so until there's a little bit more data really differentiating which patients fall into this, like higher risk group and lower risk groups to kind of probably keep practice habits the same as they have been historically, unless you took anything different from that commentary, I would agree with that.

Dr. Noble Molek (58:58)

I think from a practical standpoint, the things that I think that are challenged to do for hospitalists is the serial chemistries and who is responsible for keeping up with that in the kind of the shift work that we kind of function in. But I think it's really challenging to be so nervous about things like osmotic demyelation, demyelation syndrome, and we worry about overcorrection.

Dr. Moni Amin (59:25)

Before we round out with a little periop discussion, I wanted to bring in Kirsten because one of the deepest anxieties I have in medicine is the three letter abbreviation tpn. And I understand you went to a TPN talk. So I want to learn. I want to learn everything you learned.

Dr. Kirsten Kennedy (59:43)

I did go to that talk. I have to tell you, I'm a little disappointed that I'm not closing things out because TPN is so exciting. But I'm still happy to be here. This is like a bucket list moment

Dr. Meredith Trubitt (59:53)

for me being with you guys.

Dr. Kirsten Kennedy (59:54)

Happy to have you excited to talk about tpn. So listen this. I specifically chose this one because I felt like the lineup during that hour was packed. There was heart failure, there was ID stuff like I wasn't sure who would go to tpn how. And like, I honestly am rusty here. I kind of feel like you. So it was a great talk though. And I took away really three key pearls, right? So I want to share those with you. So the first takeaway was really having some logic to the decision to start feeds so you can see it when you're taking care of patients. It will vary. Some people feel like, oh, they just need to be NPO for a couple of days. Let's just start some IV fluids, keep them hydrated, not worried about it. But I loved the approach that they had to deciding when you need to start feeds on a patient, even if it's going to be just 24 hours of MPO. And so a lot of that had to do with their baseline nutrition status. Right. Which may not be something that we always think about. So the rule of thumb was if it's a really well nourished person, they could wait up to seven days not getting any nutrition, just IV fluids, and they would be fine. If they were nutritionally at risk, then that would probably put you at about three to five days of them going without some sort of parenteral nutrition, and they would be fine. But if they have malnutrition or if they're malnourished in any way, then you need to start immediately, even if it's going to be brief. And the thing that I also took away from this was making that decision about whether or not they're malnourished or if they're at risk really gets back to the physical exam.

Dr. Suchita Sada (61:30)

So it's.

Dr. Kirsten Kennedy (61:30)

We all know not to look at the albumin. We also should know not to look at the pre albumin though, because it can lead you astray. But really getting in there and examining the patient and looking for things like muscle wasting and fat loss and grip strength and things like that to make that decision. So I love that and I needed that. The second rule of thumb, obviously, whenever we're going to start tpn, we love to call on our licensed dietitians to help us or our nutrition team. Always a good move. But if they're not available, if you realize you've got to go ahead and get it started, they have a rule of thumb that I've decided to call the rule of 25. So they didn't call it that, but that's what my brain did. So the rule is 25 kilocalories per kilo per day, right. Thinking about the calorie content, 25mls of fluid per kilo per day. And because even if you are NPO with a terrible ileus and laying in your hospital bed, you still are held to these protein expectations. A little bit of personal trauma coming through right now. You still need 1 gram per kilo

Dr. Caroline Coleman (62:33)

per day of protein.

Dr. Kirsten Kennedy (62:35)

So I was like, man, even if I had like a terrible ileus and couldn't take anything by mouth, you're still going to get on me about my protein intake. Yes, we are. So rule of 25s, right? 25 kilocalories per kilo per day, 25mls of fluid per kilo. Per day and you still patient in the ICU are not getting enough protein and you need 1 gram per kilo per day. So I feel like you're about to say something.

Dr. Meredith Trubitt (62:58)

No, keep going.

Dr. Kirsten Kennedy (62:59)

Are you going to say something, genius?

Dr. Meredith Trubitt (63:00)

No, I want you to keep going.

Dr. Moni Amin (63:01)

Okay.

Dr. Kirsten Kennedy (63:02)

Okay.

Dr. Meredith Trubitt (63:02)

I think I have questions at the end.

Dr. Kirsten Kennedy (63:04)

Okay, wonderful. Oh, wait, maybe I won't be ready. All right. But the third, the third takeaway is we always worry about clabsi risk in patients that we start on tpn. And sometimes that is the reason why we say, let's just hold off.

Dr. Suchita Sada (63:18)

Right.

Dr. Kirsten Kennedy (63:18)

It's not going to be that long. We'll just do fluids for a day or two. But what they talked about was actually there's some emerging literature, actually one study, it sounds like that is being written, where they've looked at that and that risk may be overstated. As long as you are adhering to the evidence based guidelines for care of central lines, for that maintenance, the bundled care, then actually the risk of clabsi with parenteral nutrition is not as high as we once thought and probably, probably shouldn't be. What holds us back from feeding our patients?

Dr. Meredith Trubitt (63:51)

So my question is all of my patients are malnourished. And so it's interesting that it's so quick to start it because I think often the other reason you want to wait a few days is you're wondering, what am I bridging to? And so I'm curious if they talked about kind of the bridge to nowhere questions of TPN or just left it with kind of the nutrition aspects of it.

Dr. Kirsten Kennedy (64:15)

You know, I don't think we really talked about the bridge to nowhere. It's a really good question though. I guess, you know, I'm going rogue here. All right, don't, don't edit me out. I'm going rogue. But like, still, I think the point that they were trying to get across is that we sometimes default to not feeding, overfeeding because of whatever, you know, concern that we have, whatever risk we think is out there. But at the end of the day, a patient that is trying to heal from something needs that nutrition. And so I feel like the takeaway from this talk was really like, how do we err on the side of feeding and providing nutritional support in a safe way as opposed to giving in to reasons to not feed?

Dr. Moni Amin (64:54)

Yeah, almost surgical in a way, because that's really a surgical rule of thumb. I feel like my disagreements with surgery in that space have often been that I am a little bit maybe too cautious and they to me feel a little bit more on the aggressive end. And so it's interesting to hear that coming at a hospital medicine conference and it's only way to start changing hearts and minds is to start having the conversation. So, no, that's really helpful guidance on the TPN question that I still get a lot of chest pain about.

Dr. Meredith Trubitt (65:25)

So, yeah, I feel like it's going to change the conversation in our office.

Dr. Kirsten Kennedy (65:29)

I hope this helps with the chest pain though.

Dr. Moni Amin (65:31)

Maybe. Possibly.

Dr. Kirsten Kennedy (65:32)

Okay.

Dr. Caroline Coleman (65:34)

I don't know.

Dr. Kirsten Kennedy (65:35)

All these questions. Nobody else got questions.

Dr. Noble Molek (65:38)

Did they talk about how TPN affects the hangry scale of our patients?

Dr. Kirsten Kennedy (65:41)

They actually did. So. Okay, listen, there was a study that they cited and I'm blanking. I'm not well prepared.

Dr. Suchita Sada (65:47)

All right.

Dr. Kirsten Kennedy (65:47)

It's my first time here.

Dr. Moni Amin (65:48)

Don't judge me.

Dr. Kirsten Kennedy (65:49)

But they actually, there was a study that they cited where they actually don't think that it impacts the patient's hunger drive. Like there's this thought that if we're giving them parenteral nutrition that they're not going to want to eat by mouth. And that may not be true. Listen, they were all about starting some parental feeds if you need to. Okay.

Dr. Meredith Trubitt (66:10)

It was a great talk.

Dr. Moni Amin (66:11)

Awesome. Thank you. That was great. So I think there were questions, Kirsten, because we all struggle with this and it has nothing to do with your delivery. It was fantastic. It was more just us being like this gives us lots of anxiety still. All right, so bring us home, our periop friends. There was achy breaky hard. No hit. Why would it be hard? We're talking about hip fractures. Hospitalists don't do we don't we?

Dr. Meredith Trubitt (66:32)

No major heart surgery.

Dr. Moni Amin (66:33)

We do not. And then I know that you went to a periop update snowball, so I'll kind of let you guys steer the next few minutes.

Dr. Meredith Trubitt (66:40)

Thanks. Do you want me to start with the hips? As flipping through notes vigorously. This one was good. It's obviously specifically on hip fractures and there's I think a lot of places that do wide varieties of co management structures and things like that. But I will say for us, we really don't have that. And so these patients end up on our service and kind of don't always have like a great idea of what I'm doing. I thought he framed out a few things that I think were helpful for thinking about hip fractures. One, it is not an elective surgery in the way that you think about other elective surgeries. Person has like broken hips, they need to go to the OR very quickly. And so it is not even thinking about optimization prior to going to the or. It is really trying to mitigate major risks of whatever current active issues are going on. But to not really delay that time to the or. Then the other two that stuck out to me because it's going to tie into what we were talking about earlier is that also from the American association of Blood Banks, which I don't think we have ever mentioned in a recap, but now we've mentioned it about four times. Threshold for hip fracture for transfusion is also not seven, but actually eight and it's not a mandated eight. You can obviously still look at your patient and decide, but part of the reason for that is the famed EBL that always says, you know, negligible blood loss during the procedure. And the hospitals always are like, oh, those surgeons don't know anything. This person lost a ton of blood. He made the good point that like bleeding does not start at incision and stop at close. It really started from the time of the fracture and will actually continue up to two to four days postoperatively for the nadir to exist. So you should be expecting to see ongoing hemoglobin drops as in their post op period. And so having that higher threshold in mind to kind of help support them through that I thought was really helpful to think about and did bring up IV iron, which in this situation if they are iron deficient certainly can do. But because it's essentially an acute blood loss state, no different than a GI bleed or things like that where you may be giving them like ongoing transfusions, it's kind of up to the provider and you as like and the patient kind of deciding if IV iron or ongoing transfusions would be helpful. There's a ton of other things he hit on, but including like thinking about what type of surgery they're going to need. All these other things, some of the anti platelet VT prophylaxis, but not much of that has like necessarily been changed or different or blew my mind that much. The last thing though that has come up recently for me is just reminding us to be more proactive in these patients and thinking about bisphosphonate therapy after the event. I think he said about like 10% of these patients end up getting like they of the ones who are obviously need bisphosphonate, only 10% tend to get it, which is very low. And it's not necessarily that they should get it during the acute hospitalization, but really having that set up for their primary care or like after their ortho visit that they are okay for that bisphosphonate therapy but having like steps going forward to in their transitions of care. So I thought all that was helpful.

Dr. Moni Amin (70:04)

Yeah, that's really helpful. I don't think I've thought about bisphosphonates in a while as a hospitalist. So that was what a throwback. Great. Noble. What did you get from your periop updates?

Dr. Noble Molek (70:17)

I learned a few things. Every time I go to a perioperative session I'm reminded about how somehow little we might be able to intervene or affect the course that happens with a patient. But a couple reminders that I heard with SGLT2 inhibitors which we know are like a wonder drug and do a lot of things and it's also been shown to help with a lot of mortality benefits in people who get surgery. But the teaching point is that if they have to have surgery and they happen to get their HGLT2 inhibitors, don't delay the surgery, do the surgery. And I think that's something that pops up, I don't know at my cast like it pops up all the time that they should not get surgery, but so do the surgery if they need to. And another thing I think as hospitalists, even though we don't, sometimes we don't see them before the surgery, but I think many times we are involved with them as they are thinking about surgery and deliberating about surgery. And then I think it's a reminder that as hospitals we have a to remind the patients that one of the topics that they said is that many patients would not elect to do surgery if they recognize that they would get cognitive impairments or more frailty or not be able to go back to their previous level of functioning. And unfortunately there's been studies that shows that 30% of the patients who get surgery or people who die, 30% of them might have surgery within that first the year before they die and a certain percentage a month before they die. And so I think these conversations that maybe I don't have enough with my patients is to get a sense of like what do they really want? And I could think people, I would just say people think surgery is going to help them. But studies would suggest especially with frailty and other things that they don't. And one out of four in this particular study that was not hip surgeries or knee surgeries, but other types of surgeries weren't able to go back home immediately at least which is a lot. And so I think people might change their mind about or at least Think reconsider whether or not they want to do surgery or not. And then another thing which I thought was really great was for anxiety right before surgery about the use of music therapy right up your lally. But it's supposed to be mellow tunes, as you might imagine.

Dr. Meredith Trubitt (72:34)

So a lot of heavy metal minutes.

Dr. Noble Molek (72:36)

Well, heavy metal works from the surgeons in the or. So they talked about. Surgeons who listen to ac, DC and rock do better with like laparoscopic G

Dr. Moni Amin (72:45)

tube placements, keep their adrenaline pumping or something to just like.

Dr. Noble Molek (72:49)

But for the. It's not great for the patients, but I think for the surgeons, perhaps. So

Dr. Meredith Trubitt (72:55)

as far as kind of the, you know, mortality afterwards, they brought that up in the hip fracture one too, that at time of admission that consider that a sentinel event for this patient and should warrant a goals of care conversation so that you get a good idea of, you know, what was their functional status before this event and to lay out, you know, what are these? What is your post op time going to look like as well and see if that changes any of their thoughts on kind of what would be next best steps.

Dr. Moni Amin (73:26)

Great. That was a good peri op roundup there.

Dr. Suchita Sada (73:29)

I can jump to the EKG talk I went to because I think there's a really good teaching point that Steph Sherman and Zabin Sarg from Baylor brought up about qtc. And they talked about something I had never really heard about before called the jt. And if we're talking about, you know, tearing up your heart here with medications that might increase the JT is what we really want to think about when we're trying to say bye, bye, bye, you guys, come on. My elder millennial is coming out. Dr. Hunt. These are in sync references to Justin Timberlake.

Dr. Dan Hunt (74:05)

You completely lost me, but thank you.

Dr. Suchita Sada (74:09)

What Zaven and staff were teaching us was that the risk of torsades happens during the repolarization phase. And the qrs. And the QT includes the depolarization and the repolarization with the QRS being the depole and the JT being the repol. So if the QRS is prolonged, we all kind of think about correcting for the QRS being very wide, but they put out the math that you can subtract how much is a QRS excessively long and subtract that from your qt and then that will give you a better idea of like a modified QT correction. And you can go to mdcalc.com or your favorite app to do this math. So I thought that was really important to think about. Even though we might see numbers, it might not be the right math. And thinking about JT being that one that makes you cry a river.

Dr. Meredith Trubitt (74:59)

Does the MD calc come up with a Justin Timberlake picture?

Dr. Suchita Sada (75:03)

I don't know if it's gonna be the mug shot or not, but I'm

Dr. Moni Amin (75:06)

sure we can find that the delirium is real on this recap session.

Dr. Meredith Trubitt (75:11)

So it's Brittany, Justin and Mean Girls.

Dr. Moni Amin (75:15)

Fire for the millennials. What else did you take away from that EKG talk?

Dr. Suchita Sada (75:19)

Oh, that EKG talk was so fun. I didn't realize I would have fun like looking at tiny little squiggle marks from the back of a really crowded the conference room. But one other really important point that I thought they made really well was this concept of occlusion mi. I hadn't heard that term before because I thought things were an NSTEMI or a stemi, but they pointed out that ST elevation mi, not all things that have occlusion and plaque rupture are going to cause ST elevations. In particular, you can have stuff t depressions in v1, v2, v3, and like that early R wave peaking. That's a sign of a posterior mi. And we could go and try to get that posterior ekg. Or you can flip your EKG upside down, which is why they called it the posterior stemigorgon, because it's hiding in the upside down. I'm never going to forget that the Stranger Things reference is. But yes, the occlusion MI is a newer term for things that are occlusive for the LAD or occlusive for the lesion, but not meeting the traditional STEMI criteria. So I thought that was a really good take home. Point is, don't forget that not all things you should call the cath lab about are going to be your classic ST elevations.

Dr. Meredith Trubitt (76:38)

I never saw Stranger Things. That's what I'm taking away from this

Dr. Moni Amin (76:41)

same something about the upside down. I'm not sure.

Dr. Suchita Sada (76:44)

Wait, hold on. A pop culture reference that I know and that Meredith and both of us failed.

Dr. Meredith Trubitt (76:48)

I will say Stranger Things was partially filmed in my neighborhood, so if that counts for anything. But I didn't get the reference.

Dr. Moni Amin (76:57)

We are getting off the rails very quickly today. I'm going to keep it moving, guys.

Dr. Meredith Trubitt (77:01)

Great.

Dr. Moni Amin (77:01)

Richard, you went to a talk on derm, which not the easiest thing to do in podcast form, but I'm curious what you took away from it that our listeners can glean.

Dr. Richard White (77:10)

Yes, dermatology is always a talk I go to because it makes me uncomfortable and it's and it's very helpful to see all of the pictures every year. But a couple of quick pearls that I can hopefully convey in non picture format. We talked a lot about some of the severe dermatological reactions we should recognize as hospitalists. In particular things like Stevens Johnson syndrome 10 or toxic hemodermal necrolysis and dress. A couple of quick things. The most common culprit as a cause of Stevens Johnson or 10 is Bactrim. So something we should be thinking about for a lot of our patients in hospital medicine who are started on those medicines and then in terms of distinguishing between things like sjs or toxic epidermal necrolysis versus something like dress, both very severe reactions, often due to drugs. Timing is really important so we brought up the idea of doing like a drug chart for these patients where you literally map out which medications they're getting on which days when the rash starts and can really help distinguish between the 2. So SJS and 10 typically 4 to 21 days after medication exposure. And this is repeated exposures dress on the other hand 2 to 6 weeks after the exposure. So there is some overlap there but can really help distinguish the two. If you're having a patient with a severodermatologic reaction, want to get some initial sense of what it might be and

Dr. Meredith Trubitt (78:32)

their one time exposures. Right. That's all they need.

Dr. Richard White (78:35)

Typically not typically, multiple exposures is going to be really the patients you're going to worry about.

Dr. Moni Amin (78:40)

Great. I always also am very terrified of rashes. One of my favorite attendings in residency had a blog called I hate rashes. And so every time there's a derm talk I run in the other direction. I salute you for your commitment to learning about the things that scare you because I always struggle with the derm stuff. Okay. I know we did a bit of an ID potpourri earlier, but there were a couple other points from a home antibiotics talk I know Suchida went to that we wanted to hit. So would you mind?

Dr. Suchita Sada (79:07)

Yeah, absolutely. This was by Dr. Megan Brooks out of Ochsner. And one thing that I think is going to possibly change my practice is the idea of a single dose aminoglycoside for patients with possibly resistant UTIs.

Dr. Kirsten Kennedy (79:21)

Right.

Dr. Suchita Sada (79:21)

I know. Mind blowing. How do we avoid admission for patients and keep people out of the hospital who don't want to be there and avoid everything bad that could happen. I get scared of aminoglycosides. Like I hear gentamicin, I say bye bye kidneys. Right. But what Dr. Brooks pointed out is that there's these meta analyses that look at moderate. Let's say that one dose of something like gentamicin has moderate certainty of microbiologic cure in the patients with previous history of resistant organisms growing in their urine cultures. Even in patients with pilo, we can treat them with just one dose because it hangs around for long enough. It's mostly meeting the criteria to cover the patient for like, the three days of usual therapy that they might get. This, of course, is your stable patient who is not having sepsis, doesn't have a chronic kidney disease issue, that you really gotta worry about the kidneys. But the one and done doses have extremely rare adverse events with a single dose of gentamicin. So I think I might try that for the right patient who I might want to avoid admission for.

Dr. Dan Hunt (80:27)

Wow. Stuff I learned an internship back when the earth was cooling is coming, coming back. Immunoglycosides.

Dr. Moni Amin (80:34)

I saw Dan's face as you were saying that. Such a. I was like, well, he's going to have a comment about this and I'm so glad he shared whatever that comment was.

Dr. Dan Hunt (80:40)

It's useful.

Dr. Suchita Sada (80:43)

Are we just too scared of, like, the textbook side effects?

Dr. Dan Hunt (80:47)

Yes, we are too scared of that.

Dr. Suchita Sada (80:50)

So this is a me problem.

Dr. Dan Hunt (80:53)

Is it a generational problem? I don't know.

Dr. Moni Amin (80:56)

Well, I mean, you know yesterday when we were talking about the bacteremia treatments and stuff and talking about like, streptococcal infections needing only a couple days. Those were first published in the 40s and 50s, so this stuff does come back around. And yes, I just Talked about the 40s and 50s in reference to something Dan said. So, you know, I'm going to save

Dr. Suchita Sada (81:17)

you here, Moni, and move to the other teaching point I got from Dr. Brooks on bone and joint infections. I am also used to these needing to be treated with IV antibiotics for a long time. I guess a quick reminder is that antibiotics and medical therapy are not a substitute for surgery, even though it might take a lot of multidisciplinary conversations to advocate for a surgical cure for our patients. But the OVIVA trial that came out in 2019 and then the 2025 meta analysis really confirmed a lot of findings that PO therapy with antibiotics for bone and joint infections is not inferior to prolonged IV antibiotic course. And these are for the patients who've had surgical source control if you know what you're treating. So you have your tissue culture or you have your intraop cultures, and the patient's going to take and adhere to the complex medication regimen which Might end up including like a combination of fluoroquinolone or something with rifampin and not fluoroquinolone monotherapy, but the IV antibiotics not being a gold standard anymore, but the gold standard being a good outcome for the patient was something I took away from Dr. Brooks's talk.

Dr. Meredith Trubitt (82:34)

Yeah, I think each year we have come the antibiotic sections are for shorter duration, push for more orals, and I think this year has been no different for sure.

Dr. Moni Amin (82:45)

And Caroline, I knew you had a bit of a sepsis 26 update that you wanted to share before we get to some of the updates in hospital medicine papers that were covered.

Dr. Caroline Coleman (82:56)

Yeah, there's so much ambiguity in how we define sepsis. And any residents that have worked with me will know that this is one of my favorite teaching points because we have so many different ways to define it and that's based on the different incentives we have when we're charting. So just to recap, there's been several iterations of Sepsis 1, 2 and 3 guidelines. Sepsis 2 was prior to 2016 and is something that we all know inside and out. It's defined sepsis as serves with a source, but ended up over identifying patients with sepsis, which sepsis 3 in 2016 defined as any infection that causes a dysregulated immune response. So instead of the healthy white blood cells trying to just tamp down that pneumonia, it causes end organ damage outside of that organ that's infected. And these are the folks that we really worry about because inpatient mortality, depending on how you define sepsis with sepsis 2 or 3 is anywhere from 6 to 20 plus percent and septic shock is, you know, upwards of 40%. It's one of the most morbid conditions that we see on the wards. So defining it we would think would be really important and really easy to do. But this talk just discussed why there's so much ambiguity around it, why it's such a difficult definition to nail down. And to add confusion to this, to this, is that CMS reimburses based on the SEPSIS 2 guidelines, which to some of our learners that aren't in the charting space might not feel important. But that's why you might see some ambiguity with your attendings charting sepsis 2 definitions, but teaching sepsis 3 definitions. So what do we do? We have a commitment to education on this podcast, but also a commitment to keeping our jobs. And I think the author put a very diplomatic answer to how we chart this is that the bottom line is that there is end organ damage as a result of this infection. And as long as you're charting that, if your institution requires you to chart QSOFA or to chart sirs, we can still sleep at night knowing that we're treating patients with end organ damage with that sepsis bundle of fluid and antibiotics and still teaching our learners that. There's a lot of definitions floating around. But just keep in mind end organ damage is what is so dangerous dangerous about sepsis in whichever way we slice and dice the definition. Just remember that if we treat the patients with in organ damage with those sepsis saving interventions, then that's your true north.

Dr. Moni Amin (85:23)

Yeah. So I think now we want to kind of talk about what we view as the premier talk at SHM every year, which is the updates in hospital medicine where they go over the most pertinent articles to the hospitals for the past year. And one of the ones I think we all kind of agreed on that was really kind of reshifted. How we think about some treatment for cirrhosis patients is the Carvas trial. And Suchita, you always cover liver stuff for us, so would you mind covering this for us?

Dr. Suchita Sada (85:50)

I love this trial because. And thank you, liver is so much fun. But Carvas looked at the addition of Carvedilol in patients with clinically significant portal hypertension with a first episode of ascites and with low risk or no varices. And so you don't have to have. Traditionally I think I've been practicing, if you've got your screening egd, you have varices and you start a non selective beta blocker. But this was really looking at randomizing patients to the addition of carvedilol or just standard medical therapy. And it reduced the negative effects at their follow up point of two years. And it looked at that carvedilol. Average patient's dosing was about 12.5 milligrams divided in twice daily dosing. But they stopped if the SPP got less than 90. So these are not continued in patients who are hypotensive, which I think is a really important caveat for our clinical practice. But it reduced the recurrence of ascites, it reduced the incidence of acute kidney injury. I think it really consolidates the findings from the 2019 Podesky trial that looked at not propranolol, non responders and patients with clinically significant portal hypertension who hadn't even developed ascites yet. And it reduced the incidence of ascites. So I think that the big takeaway is if we haven't already been using carvedilol as our first line medication in patients with cirrhosis and clinically significant portal hypertension. We should try to get that on board before they leave the hospital and start at 3.125 twice a day, try to get them up to a heart rate less than and around 60.

Dr. Moni Amin (87:29)

Yeah, I just can't believe that this is happening. I feel like for the longest time I remember studying for boards and it was like, if they don't have varices on their egd, you don't do any. And really this could be paradigm shifting in how we think about treating cirrhosis patients. That's really important. Trial, I think from the past year. The other one I think we all had sort of talked about was the Adopt trial, which I think Meredith would speak on.

Dr. Meredith Trubitt (87:57)

I prefer this one. This one's looking at oral naltrexone versus extended release naltrexone. As a point of, I guess, clarification, they had everyone raise their hand for who had available in their institutions oral and extended release. And Caroline and I were talking about this earlier too. We are spoiled a little bit that we have both and can offer them to our patient population. But not everyone has extended release naltrexone available to them, especially in the inpatient setting. So essentially the Adopt trial was looking at the comparison of oral naltrexone and extended release naltrexone and showed that there is really no difference in heavy drinking days across the two groups. I think that that is important because really what it is telling us is that it is going to be whatever your patient is going to do well with. So if your patient is someone who is not going to remember to take a medication every day and prefers an extended release option, then that is reasonable. If your patient is someone who has had issues with the extended release IM injections, that is an option for them as well and shouldn't be preferring one necessarily over the other, assuming that the long acting is just going to be better. So I think that that in truth is really just opening up our options, options for what we're able to do for our patients.

Dr. Moni Amin (89:14)

I always like having more tools in our kit when we're treating patients with those issues.

Dr. Meredith Trubitt (89:19)

And that's for alcohol use. If I didn't mention that at the

Dr. Moni Amin (89:21)

beginning, I know I talked a little bit about steroids and community acquirer pneumonia yesterday, but we were talking as a group about the trial that they mentioned from the Lancet respiratory therapy. Dan, I was curious if you would mind talking a little bit about what we found specifically in The CRP space.

Dr. Dan Hunt (89:43)

Yeah. So this, this trial looked at other predictors of when steroids might be beneficial for patients. And PSI and the other risk predictors we typically use did not predict benefit. But it was clear from the trial that CRP elevation did predict that the patient would benefit from steroids. The units that were given in the Lancet article were above 200, which we're all talking about at our table. That seems really high. So we're going to need to check the units on that. Yeah. But the take home message here is check a CRP when the patient's admitted with pneumonia.

Dr. Meredith Trubitt (90:19)

Yeah. And I think that was the summary we got to yesterday too.

Dr. Moni Amin (90:24)

I think so. Debatable.

Dr. Meredith Trubitt (90:28)

Who remembers yesterday?

Dr. Moni Amin (90:32)

They always round out our talks with some of the fun studies they did. A couple. One was about ChatGPT4. There was the. They had conventional resources and then conventional resources plus ChatGPT 4 and then they just had ChatGPT. And it seems though, as though conventional plus ChatGPT, while it took them a little longer to get to the answer, they were more often correct in their. They were, the users were given cases to ask for more information and then kind of go back and forth. And it seems like using all your resources provides you with better information. So that's something that I think is good to know. And I think the premise is always, are we going to be replaced? And at least for now, it seems as though humans do have a role in the care of patients.

Dr. Meredith Trubitt (91:20)

Can I do one more?

Dr. Moni Amin (91:20)

Great.

Dr. Meredith Trubitt (91:22)

I do just want to. The ChatGPT4 trial that they brought up is kind of was in the part of their talk that was like, things coming down the pipeline kind of be on the lookout for, but not necessarily ready for like practice changing mechanisms. And the other one that they brought up is suzetragine, which I know not everyone has available to them, but I do think it's something that should just be on everyone's radar. It's, it's very new kid on the block. But for pain management in the acute post op phase, really for those first 14 days after an operative procedure, suzetrogine is kind of an opioid sparing option, inhibiting sodium gated channels. And at least in the studies that the company did, it showed very similar pain relief as hydrocodone acetaminophen combination. So I think more data is going to come down and I think also expanding where suzetrogene is going to be used will kind of be coming down the pipeline soon too. And so just Having it on everyone's radar, I think was an important thing to highlight during that talk. And then I think the other one that we hit on at the beginning was Metformin. Metformin was a VA trial. So shout out to the VA and I actually, the three of us here who work at a va, I was so fascinated actually by that initial table where they were like the place that it's facility centric who continues Metformin on hospitalization. And I couldn't agree more. I know that it depends completely on the nocturnus that I got sign out from whether that Metformin is continued or or not. So I don't know where ours landed in that like, table, but I found that really like, interesting. But at least from kind of that data, it looked like for those that did continue Metformin throughout the hospitalization, improved mortality, fewer readmissions, less new insulin prescriptions at discharge and less post discharge hypoglycemia, which I think in some ways actually, actually sort of makes intuitive sense that it's a medicine that they were on at home. We have stopped it. It has impact when you are not taking that said medicine in the hospital. And now what is going to happen on the outside again can be a little bit uncertain. So definitely in your patients with like GFR is greater than 30, seems reasonable to continue it, barring, you know, any other major concerns for lactic acidosis. And that is the major limitation to the study is that it really didn't measure those inpatient parameters very well. So I think like cautiously think about the patient that's in front of you, but can consider continuing it in the inpatient side.

Dr. Moni Amin (94:12)

Great. And to round us out, I think for our recap, we should probably talk about the updates in diabetes management. I know it's been a while since we've covered it for the inpatient side and the world has changed aplenty since we last talked about it. So we had a great talk this morning on the last day with diabetes updates in diabetes management inpatient, obviously. And I think I wanted to start the discussion, starting with the technology piece because that stuff has moved so quickly in the last several years. The COVID era had sort of guidelines just to make sure that we were keeping everybody safe. CGMs were allowed inpatient, and then there was kind of this move away from them as an inpatient and to my understanding, still in general for just the CGMs. Takeaway from this talk was that it's not FDA approved for inpatient use. Though if you are going to use them, a lot of encouragement to validate, to check twice a day, point of care, glucoses, because generally there tends to be a 5 to 15 minute lag time and then there's also 20 to 20, 25% variability in glucose readings. And I found that to be interesting. I know you did too. Comparing that with kind of what the recommendations were for people on insulin pumps.

Dr. Meredith Trubitt (95:34)

Yeah, it's, I don't wanna say they're like contradictory, but you can just like, for those of us, I think, who work in the hospital full time, you can see where this is going to fall apart in a way. But yeah, like the CGMs, you know, no regulatory approval, but the ADA is recommending like, can use it if that's what the patient's comfortable with. But then kind of comes in the questions of like, what is nursing comfortable with? What are you as a hospital comfortable with? And then in addition to that, the ADA is now like recommending really that the automated insulin delivery systems are, you know, first line Therapies for type 1 and type 2, assuming that the patient is in a cognitive space and physically able to manage it. So I do agree with what the presenters were saying, which is, is, you know, where you're going to see all of this technology in the hospital setting in probably very short order. I also agree with what they said, that they really, I think, cautioned providers to be very aware of what can your hospital do. So do you have the resources, do you have the, you know, education to, you know, ancillary staff, nursing staff, do you have all of the supplies for them to be using their CGMs? And if something's not going right, how are you going to be validating it? How are you going to confirm all this? Because this is a system that's really designed for the patient in a stable outpatient setting, not in the wildness of

Dr. Moni Amin (97:01)

the wards or icu, definitely not using these in critically ill patients. And some of the safety issues they brought up to keep in mind, as you're thinking through all that would be these insulin pumps need to be refilled every three days and if you run out, the development of decay is pretty rapid and then you would immediately need to stop the pump and start IV insulin. So really important to keep some of those safety things in mind.

Dr. Meredith Trubitt (97:25)

Yeah, and I think that also is interesting, this being near and dear to me a little bit. But, you know, they talked about how if that happens in the hospital setting, you're gonna have to switch EM to long acting like basal insulin and then short Acting bolus. But ultimately, when the patient's getting ready to go home, you're also then going to have to, you know, switch them back to the pump, which will be all short acting again. So you're kind of going to, I think, you know, if you're doing that, really be increasing length of stays and stuff. So I think it's going to be right for a lot of like, good quality improvement. A lot of policy development in the hospitals, but found it very interesting, for sure.

Dr. Moni Amin (98:02)

And just as technology's rapidly progressed, as has the oral management of diabetes. And no, look no further than the SGLT2s and how far they've come along in the four years we've been covering SHM. And a few things that I found to be notable. I think the biggest was their discussion around UTIs actually. So I think there's been this idea for a long time that if you've had a UTI or you develop a UTI while on an SGLT2, then you really shouldn't restart it. That that's just like a hard contraindication. And based on, I believe, the update for ada, the idea is that you pause it when someone has an acute uti, but you should restart it after resolution as the risks do not outweigh the benefit. All the other benefits that these medications provide and the real, only true absolute contraindication is the development of dka.

Dr. Meredith Trubitt (99:01)

Yeah, I agree. This has just come up with my, like in my practice recently a lot as a question, you know, person found to have history of UTIs, maybe several years ago, maybe it was an anatomic issue that was, you know, fixed or rectified. Now what do you do with SGLT2? And so I thought kind of their framing with, you know, having it as, you know, weighing it as a risk benefit with these medications that have such profound benefit for many of our patients, you know, the risk of it is probably needs to be more than just the one uti. I did like that they said, you know, it's probably worth a conversation with the patient and things like that. So it did help me kind of reframe it a little bit though. Not just one and done.

Dr. Moni Amin (99:48)

Yeah. And the other thing about SGLT2s and we'll have the exact cutoffs for the GFRs in this, in our show notes. Just don't want to misspeak. But they did lower the GFR threshold. Like a lower GFR would still allow for the cardiorenal benefits. So you can still give it for the cardiorenal benefits. At a lower GFR than was previously recommended. I believe they said 20 specifically for cardiorenal. Did you have anything else for the SGLT2 section of that?

Dr. Meredith Trubitt (100:17)

No, those are my big takeaways.

Dr. Moni Amin (100:19)

Great. Moving sort of to the other hot medications for diabetes for a whole multitude of reasons that we will not get into in this are the GLP ones. And I guess one thing that I didn't realize, mainly because I don't see them a whole lot, is just the full A1C reduction that they can provide. 0.8 to 2% depending on the medication you use. That really wasn't, like, the stuff that I think you and I both were really thinking about when we left. It was really a discussion around pancreatitis.

Dr. Meredith Trubitt (100:51)

I'm sure you have had this happen to you on the inpatient side. Patient recently started on a GLP1 or recently increased doses of the GLP1s and then they're presenting with an acute pancreatitis. And so we're all like, oh, man, we knew these GLP1s had to have something wrong with them. Must be this pancreatitis. But they actually shared a nice study, which we'll link in the show notes by Ioob and his team, which actually showed that patients with, like, when they did propensity matching, the patients that were on GLP1s actually had lower rates of pancreatitis. And it's kind of the risk factors and confounding around the other risk factors that warrant someone being on a GLP one that may be more indicative of why they're having pancreatitis in the first place and so can be considered restarting after the acute pancreatitis. So still recommend to stop it during the acute flare, but could consider resuming it at a later time. So I thought it was a really nice graph, actually, that they showed from that study, which also, I don't know, you and I kind of want to hate on the GLP ones because they seem too good to be true.

Dr. Moni Amin (102:00)

Yeah, we do have healthy skepticism, but data keeps coming out that they're beneficial. And I think that you follow the data and until the data changes, these seem to like really great medications to be giving patients for a whole multitude of reasons. And it seems like this one concern, that a lot of people had this possible association with pancreatitis seems to not really actually be something we need to worry about. Which is. Which is great because these medications are doing a lot of great things for patients. Now, I know we spent a lot of time talking about these new school, but I think we're going to close out with the tried and true the insulin specifically subcute insulin in the management of the in mild dka and specifically we won't get in the exact doses here, it'll be in the show notes. But to manage mild dka, generally speaking it's weight based insulin dosing for both the long acting that you give and then short acting. The thing to keep in mind however is that this is incredibly resource intensive. So the idea is like oh, one less ICU patient. But all the discussion was these are like hourly to Q2 hourly point of care glucose checks plus a Q4 hours BMP to make sure the gap is closing. So probably still at least a step down or intermediate level care patient if you have that at your hospital. So it sounds great that they wouldn't necessarily need to be on a drip in the icu. But the resource intensiveness of these protocols something to keep in mind as you think about changes to your hospital policies and protocols. But I did think it was interesting because I know when I was in training it was dripper bust when you saw that gap.

Dr. Meredith Trubitt (103:41)

Yeah, no notes. I completely agree. The Q1 to 2 hour glucose checks, especially for those first few hours. Again same as like in the tech section of this one. I think the resource limitation is going to dictate a lot more

Dr. Moni Amin (104:00)

and that'll kind of round out our recap of SHM converged 2026. As always, we're really grateful that the SHM team has us back. It lets us record these episodes and highlight some great speakers. And with that, this has been another

Dr. Meredith Trubitt (104:15)

episode of the Curbsiders, bringing you a little knowledge food for your brain hole.

Dr. Moni Amin (104:18)

Yummy.

Dr. Meredith Trubitt (104:19)

Still hungry for more?

Dr. Moni Amin (104:20)

Yep.

Dr. Meredith Trubitt (104:22)

Join our Patreon and get all episodes episodes ad free plus twice monthly bonus episodes at patreon.com curbsiders you can find show notes@thecurbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox, including our Curbsiders Digest which was shouted out at SHM this year, recapping the latest practice, changing articles, guidelines and news and internal medicine.

Dr. Moni Amin (104:42)

And here at the Curbsiders, we're committed to high value practice changing knowledge. And to do that we need your feedback. So please email us@askcurbsiders gmail.com it also helps a lot when you subscribe, rate and review the show on YouTube, Spotify or Apple Podcasts. A reminder that this and most episodes are available for CME credit for all healthcare professionals through VCU Health at curbsiders.vcuhealth.org A special thanks to our wonderful panel of guests. Dr. Caroline Coleman, Dr. Kirsten Kennedy, Dr. Dan Hunt, Dr. Richard White, Dr. Suchita Sada.

Dr. Meredith Trubitt (105:13)

That's everyone.

Dr. Moni Amin (105:14)

That is everyone. To joining us to recapping this year and our technical production is done by the team at Podpaste. Elizabeth Prota does our social media. She's been uploading our awesome pictures and videos to the Curbsiders and SHM feeds this year. Jen Watto runs our Patreon. Chris the Chew Manchu moderates Discord. Stuart Brigham composes themed music. And with all that, until next time, I am Moni Amin.

Dr. Meredith Trubitt (105:40)

And I am Meredith Trubeth. Thank you and good night.

Dr. Moni Amin (105:57)

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Dr. Moni Amin (106:05)

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Dr. Moni Amin (106:11)

But we also know how to help you upgrade those systems, lower those costs and meet the demands of your business with smart, energy efficient solutions. Find cash incentives@energytrust.org Energy Trust of Oregon. More power to you.