Hospital and Internal Medicine Podcast: Recent Episodes
Gil Porat, M.D., FACP, CPT
Intended for the medical professional who enjoys learning for the sake of it. Dr. Porat is a practicing Colorado Hospitalist and Board Certified in Internal Medicine.
The double-blind, randomized phase III EMPEROR-Preserved trial showed a benefit of the sodium-glucose cotransporter-2 (SGLT2) inhibitor empagliflozin in patients with heart failure with preserved ejection fraction (HFpEF).
Now let us dig a bit more into those headlines.
An important recently published randomized control trial provides guidance on this controversy.
Almost nobody feels comfortable managing DELAYED gastric emptying (gastroparesis) and very few medical providers even think about RAPID gastric emptying in their diabetic patients. Even if you send these patients to GI specialists, your blood sugar co-management of these patients can be heavily impacted by these issues. Is delayed gastric emptying always a bad thing? When your patient has upper GI symptoms, how often is it a gastric emptying abnormality? Time for some answers.
Can we trust a nuclear study to nail the diagnosis? Are motor abnormalities really the cause of symptoms? What is a POP procedure?
Does regular, low-dose, oral sustained-release morphine improve disease-specific health status or cause respiratory adverse effects in patients with moderate to very severe chronic breathlessness due to advanced chronic obstructive pulmonary disease? Digging in on the latest study.
My take on what went down at the Journal of the American Medical Association. I disagree with the comment there isn't "structural racism in health care", but was the backlash against the Editor who didn't say it (and actually opposed the comment) an over-reaction? Can we have discussions about the controversial issues that affect healthcare (like gun violence or abortion) without cancel culture cancelling the people who want to have nuanced discussions? I fear we lost the ability to have dialogue in a field where every MD/DO/PA/NP by definition has an advanced degree - and therefore we should be able to dispute misinformed statements to bring about change without the outrage going so far as to fire a person who actually objected to the hurtful statement.
This lecture provides a basic understanding of how epigenetic changes influence infections/sepsis, vaccinations, cancer, future generations, your muscles, and (of course) those sweet tan-lines you are rocking.
Every day you are living through epigenetic changes that have huge implications on your health and who you are.
Hyponatremia remains a challenging topic for many because they are trying to memorize algorithms and numbers. You can usually nail the etiology by history & physical and a brief chart review.
If you use the term 'cytokine storm' and don't really know what you mean by it, you are far from unique. Let me help to try and clarify it for you just a bit.
Do you know what CRP is (other than saying it is an inflammatory marker)? Should we always shut down cytokines? If so, how? Why should we avoid giving a glucocorticoid to a COVID patient before they develop an elevated CRP or hypoxia? So many questions! A few answers are provided.
Dealing with hypoxia, anticoagulation, steroids, Remdesivir, VTE, self-proning, labs, plasma, etc.
I do not get into the epidemic numbers or politics or vaccines or outpatient treatments (this is really a HOSPITALIZED TREATMENT discussion for frontline providers in hospitals). Some of what is discussed is likely going to change over the next months, as has often been the case with COVID19.
Multiple treatment issues are discussed. This includes theoretical ideal blood pressure lowering rates, oral options (for hypertensive urgency and specific populations), intravenous options (for hypertensive emergency or NPO patients), specific issues with aortic dissection, coronary syndromes, acute pulmonary edema & heart failure, labetalol, esmolol, nitroglycerin, and nitroprusside.
Did you know that intravenous labetalol and oral labetalol are not really similar? The great hydralazine debate. Things you must know about Clevidipine if you are going to use it.
Did you know systolic and diastolic blood pressure are NOT measured by automated BP cuffs? PRES (Posterior Reversible Encephalopathy Syndrome), also known as RPLS (Reversible Posterior Leukoencephalopathy Syndrome), is something you should recognize when you see it. Brief mentions of esmolol, nitroprusside, and other topics are scattered somewhere in between musings.
If you wonder why good food is more important than mortality and why ordering too many unnecessary consults worsens the food and doesn't impact mortality - this episode is for you. Tramadol is not well understood by many prescribers and there are some emerging facts we all need to know. A flashback to diuretic use in congestive heart failure with fluid overload and elevated creatinine is also discussed somewhere in the mix. Ohhh...and stop systematically prescribing nicotine replacement at high dosages for all hospitalized smokers.
Stevens JP, Hatfield LA, Nyweide DJ, Landon B. Association of Variation in Consultant Use Among Hospitalist Physicians With Outcomes Among Medicare Beneficiaries. JAMA February 21, 2020
“Twenty Common Mistakes Made in Daily Clinical Practice” American Journal of Medicine 2020:133(01):1-3
Cristobal Young, Xinxiang Chen, Patients as Consumers in the Market for Medicine: The Halo Effect of Hospitality, Social Forces
Tramadol is an odd, unpredictable opioid, scientists say - By The Associated Press - December 13, 2019
World War I was partly triggered by powerful allies of various nationalities being dragged into a Balkan conflict (nationalism, of course, was another major factor). The more recent Balkan conflict is even more preposterous - and here is my attempt to humorously explain the unexplainable.
Correcting Hypernatremia in adults (finally, a real study!). An option for that scary patient with hemoptysis. How many nephrons you have (and your patient has) - it matters.
Anemia of Inflammation is also often referred to as Anemia of Chronic Disease. It is one of the most common anemias, yet often challenging to comprehend. This is an attempt is to try and simplify it.
If you know why red blood cells survive less (and are made less) during inflammatory conditions, and already know why ferritin increases in inflammation, and don't want to hear a lousy Iron Man plot idea - then you are good to go on skipping this episode.
It occurs naturally in the body (because we synthesize it), it is in meat, and it is frequently used as a supplement. Since it is in you, why not understand what it is and what it does? Advice is provided on which supplement labels to particularly avoid. A brief reflection upon creatine within our brains (and the potential memory impact seen in one study) is utilized to make the point that when it comes to a performance enhancer, like creatine, it's not solely about the ramifications on muscle strength and endurance.
The replenishing of muscle ATP is one (of the several) mechanisms that creatine helps with when it comes to heavy anaerobic exercise. Other topics discussed are things to know about lab testing the kidneys while taking creatine. Thoughts on why some don't respond to creatine supplementation.
Is there a specific type of creatine to buy? What is creatine monohydrate? What is Creapure? What do some professional organizations have to say about the safety of creatine? The loading dose debate. Also dives into the several mechanisms of action for how creatine helps build muscle.
Are you surprised that GoFundMe and crowdfunding are not the solution to a family healthcare crisis? How about Medicare for All? Hmmmm.....
A deceivingly difficult topic. Not so obvious points are made about asymptomatic carriers, transmission, and who to test.
Specific initial treatment regimens are discussed. Topics include fulminant disease, Vancomycin, Fidaxomicin, Metronidazole, and recurrence rates/regimens.
Many of the latest studies in the 2017-2018 timeframe are reviewed. The importance of looking at the eosinophil count on the CBC, probiotic future directions, microbiome transplant options, antibody treatment (bezlotoxumab), "penicillin allergic" patients, and a brief mention of available testing.
Glucagon-Like Peptide 1 (GLP-1) mimetics are also referred to as the GLP-1 receptor agonists. While this talk mostly focuses on GLP-1 mechanisms and actions, the hope is you will also better understand The Dipeptidyl Peptidase-4 (DPP-4) inhibitors
The current GLP-1 Agonists include Exenatide (Byetta), Liraglutide (Victoza), Dulaglutide (Trulicity), Abiglutide (Tanzeum), Lixisenatide (Adlyxin), Semaglutide (Ozempic).
The current DPP-4 Inhibitors include Alogliptin (Nesina), Linagliptin (Tradjenta), Saxagliptin (Onglyza), Sitagliptin (Januvia).
Sodium-Glucose Transporter 2 Inhibitors decrease glucose re-absorbtion. The diuretic effect, weight loss, DKA, cardiac outcomes, blood pressure, genital infections and a whole bunch of other information is discussed.
SGLT2s include Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertagliflozin (Steglatro), with more to be released in the future.
There is a lot more to understanding HgA1C then most realize (particularly the quality industry and big corporations).
Tackles - Vitamin B12, kidney disease, CHF, cancer, Impaired Glucose Tolerance (IGT), dosing, side-effects, lactic acidosis, cost, drinkers, hypoxic patients, glucose lowering, and a few other moments of erudation.
If you want to understand drug classes like DPP-4 inhibitors, GLP-1 (GLUCAGON-like peptide) therapies, treating hypoglycemia, and an important player among the many etiologies of Type 2 diabetes - then you must understand the basics about glucoagon.
Diuretic therapy for congestive heart failure treatment, antibiotics for diabetic osteomyelitis after foot surgery, and practical tips with new-onset seizures - is among the knowledge dropped (because, after all, school can't teach us everything).
Some new stuff about Vitamin D & Calcium supplementation, another about the timing of hip fracture surgery, etc
Checking glucose levels in Type 2 Diabetes, ACE Inhibitors for women, and using Azithromycin in Asthma.
You know all those people on social media wanting mandatory drug testing for welfare recipients? Perhaps, reasonable in theory, if the test wasn't frequently producing false-positives and false-negatives. Making accurate clinical decisions is always challenging, but particularly with urine drug testing. The consequences of misinterpretation can be awful.
A look at some new data: COPD and Oxygen use - low serum creatinine levels - BMI considerations - the RDW - the age of blood.
Oxalate intake reduction, thiazide diuretics, and tamsulosin are some of the therapies discussed in this lecture.
Stone analysis, labs, calcium & fluid intake, sodium in the diet, and beverage choices.
You see it in energy drinks. It is in our food, supplements, it naturally occurs in multiple organs, and most people don't know anything about it.
Lifestyle, carbohydrates, protein, and eccentric weight training are part of the focus of this sermon.
This episode is part philosophy, part motivation, and a discussion of some traps men and women get caught in.
The use of Inferior Vena Cava (IVC) filters and the length of anticoagulation in unprovoked DVT/PE are considered. A rant about hyper-coagulable panels in provoked DVT/PE is opined.
Understanding what causes hypotension in PE is essential to understanding the severity of the situation. The relevance of the stressed right ventricle is emphasized. Thrombolytic therapy for hypotension and other clinical scenarios resulting from pulmonary embolism are contemplated.
The treatment challenges of subsegmental pulmonary embolism, with emphasis on the 2016 guidelines are reviewed. Ventilation/perfusion (V/Q) scan interpretations in those unable to get a CT scan are considered.
The topics covered are D-Dimer testing, false positive over-diagnosis of PE on CT scanning, the ADJUST-PE study, and clinical signs and symptoms of a pulmonary embolism.
Various topics regarding intravenous iron are pondered, especially some of the new data available that has not yet seemed to obtain the influence that the information deserves.
BNP use as a lab and therapeutic are discussed. The episode also explores the PARADIGM-HF trial and Neprilysin inhibition. The novel combination medication sacubitril/valsartan (Entresto) for systolic CHF is evaluated in depth. Clinical tips for avoiding angioedema and other clinical pearls are provided.
If you think the seismic shift in U.S. healthcare is all a result of the Affordable Care Act, you may not be seeing a large part of the picture. This has become an era of "BIG MEDICINE" and that phenomenon is increasing through mergers and acquisitions. Some of these mergers are strategic, while others are defensive. Practical advice on how doctors and companies can improve their chances of merging successfully is provided. The lecture concludes with potential implications of the insurance-industry merger wave on patients and those working in the healthcare industry.
This episode offers some advice in thinking about the very difficult topic of pancreatic pseudocysts. Some philosophical waxing about pain control and some items not addressed in the previous episodes are also discussed.
Imaging, fluid resuscitation, fine needle aspiration, determining sterile vs infected necrosis, and suggestions from the guidelines are discussed.
This episode addresses some of the debates regarding nutrition timing in acute pancreatitis. Methods such as nasogastric, nasojejunal, and oral feeding are compared.
Treatments that include hydration, cinacalcet, calcitonin, bisphosphonate, denosumab, and other options are reviewed.
Indications for parathyroidectomy, pre-operative localization issues, diagnosing hyperparathyroidism, and a brief summary of the guidelines are among the topics addressed in this episode.
Special attention is paid to gastrointestinal, bone, and cardiovascular disease as a result of hypercalcemia. Laboratory interpretation of calcium and phosphorus levels is also discussed.
Pseudomonas aeruginosa and Legionella pneumophila bacterial lower respiratory tract disease are explored in depth.
Streptococcus pneumoniae is a frequent cause of pneumonia. What makes this organism unique? Listen and find out.
Does the patient really have pneumonia? Differential diagnosis and mimics are considered in this common clinical problem. Dive deeper into how microbes and the immune system interact in lower respiratory infections.
Hepatotoxicity from antibiotics, NSAIDs, dietary supplements and other sources are explored. Idiosyncratic drug induced immune related and non-immune related injuries are differentiated, which can change treatment.
Was H1N1 accidentally released from a laboratory? Is it really a "swine flu"or is it a misnomer?What is this H3N2 swine flu we periodically hear about in the media?What makes a pandemic?Find these answers and more in this episode.
Some years the vaccine is better than others - but there is still good reason to get it. Let's discuss those reasons.How is flu transmitted?How do weather patterns influence the spread of influenza?Get these answers and more in this episode.
Resistance and virulence mechanisms are discussed. Clinical presentations as well as the difference between colonization and infection are considered.Screening, prevention, and understanding Community Acquired MRSA vs Healthcare Acquired MRSA strains can be challenging, so practical information is presented for the common questions patients, families, and health care workers will often have.
The problem with Acute Mitral Regurgitation is that it is frequently fatal unless quickly recognized. The listener will learn about organic and functional etiologies of this precipitator of acute respiratory distress. Lessons from the SHOCK trial are scrutinized to help guide therapy in the setting of myocardial ischemia.