Hospital and Internal Medicine Podcast

This episode clarifies the difference between an elevated lactate level (hyperlactatemia) and true lactic acidosis, which requires evidence of metabolic acidosis (low pH or low bicarbonate). It discusses common causes of raised lactate, why mislabeling affects treatment location and mortality risk, and how EHRs and coding practices can perpetuate the confusion.

Listeners will learn when to document lactic acidosis versus elevated lactate, the clinical implications for resuscitation and disposition, and the importance of precise medical terminology.

If you find elevated ascorbic acid (Vitamin C) in the blood, you don't diagnose the patient as having an ascorbic acidosis. Likewise, just because lactic acid is elevated in the blood does not mean it is an acidosis (though sometimes it can be - learn the difference).

Fecalomas—rock‑hard impacted stool that cause obstruction, stercoral colitis, perforation, and even death—most often in immobile elderly patients or those on opioids. Standard treatments include aggressive bowel regimens, enemas, manual disimpaction, endoscopic fragmentation, and surgery.

There are also case reports of using Coca‑Cola enemas to soften and reduce fecalomas when conventional measures failed. 

This episode examines the concerns about mouthwash and oral cancer. While ethanol can form the carcinogen acetaldehyde, how worried should we be?

Strong antiseptic rinses can alter the oral microbiome and may reduce bacteria that help produce nitric oxide, with a small study showing a blunted post-exercise blood pressure drop; does that justify abandoning exercise or ignoring dental guidance?

Multiple studies in multiple journals are going against the norms and previous guidelines. The times they are a changing.

For acute treatment of Venous Thromboembolism the debate of which direct oral anticoagulant to use appears to now be settled.

 

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. 

Hint: That person died in 2017

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.

Experiences that taught me some lessons. 

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