SPEAKER_04 0:19

Hello and welcome to Inpatient Update. I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the Working Hospitalist. Today on the show, I'm joined by two very special guests, Dr. Katie Glotz and Joe Thomas of the JHM Digital Media Team that published JHM RAPT 2025. Together we'll evaluate recent evidence featured on JHM RAP that subverts some common hospitalist reflexes and assumptions. Does gram-negative bacteremia really require continued IV antibiotics when Cipro and Bactrum aren't options? When you're worried about hypercapnia, is an APG really the best first test? And how much of that uptrending white count can you really blame on steroids? Let's get into it. Well, Dr. Thomas, Dr. Glotz, thank you so much for being here and joining me.

SPEAKER_03 1:15

Thank you.

SPEAKER_00 1:16

Thanks for having us, Dr. Turner.

SPEAKER_04 1:18

Oh, of course. For the audience, Dr. Joseph S. Thomas, MD, is a hospitalist physician in Buffalo, New York, who also serves as a clinical instruction to residents and students and as one of the deputy editors for digital media for the Journal of Hospital Medicine, focusing on videos and educational content. As Doc with Bowtie, he uses social media and has written op-eds about the importance of fighting misinformation.

SPEAKER_00 1:49

Welcome, Joe. Thank you very much for having me. Yeah. I mean, I love the journal and and I love putting positive information out there as a way to kind of help combat all the misinformation that is currently running rampant as well.

SPEAKER_04 2:05

Also, we have Dr. Katie Glotz, MD FHM. She is a hospitalist in Rochester, New York at the University of Rochester. She's interested in end-of-life care and decision making, especially for people with intellectual and developmental disabilities, medical education, and clinical bioethics. She also proudly serves as deputy editor for digital media for the Journal of Hospital Medicine with a focus on visual abstracts. Outside of work, she enjoys traveling with her husband, cooking, eating, running long distances, rock climbing, reading, and cuddling her cats. Thank you for being here, Katie.

SPEAKER_03 2:45

Thank you so much. I'm really excited to be here. And as someone who's slightly less comfortable than Joe having my video and voice out there, I still try to use the power of digital media, but in my own way, that doesn't require me to listen to myself. I'm making an exception for today.

SPEAKER_04 3:01

I love it. I love it. Yeah. I'm super stoked for this conversation and so glad you could be here. Joe, JHM Wrapped. Can you tell the audience what that is briefly before we get into the clinical content?

SPEAKER_00 3:15

Yeah. So as digital media, uh, you know, we were trying to find a way to create content. And so we started doing a JHM Wrapped that was around the same time as Spotify Wrapped, to where we would kind of round up articles, you know, things that people had been reading and clicking on throughout the year, kind of similar to how Spotify does their algorithm and their uh little end-of-life or end of life, end of year um uh summary. So we wanted to do something like that. And then, you know, as as time went on and we we sort of realized how many articles we wanted to talk about, and and we realized that we could get this published uh in and of itself as as an article, a little bit of self-promotion, I guess, um, but all uh you know, for the journal, but also a way to highlight some of our great authors and some of the great research we've done. And and then JHM Rep was uh as an article was born. Joe, how often do you order an ABG on the floor? These days, not as often as I as I used to. This article is actually kind of near and dear to my heart because as a as an intern, I used to let med students practice ABGs on me. At least I did for the first couple of months.

SPEAKER_03 4:32

Very bold, Joe, very bold.

SPEAKER_00 4:35

Well, then my my then fiance who I'm now married to found out I was doing that, and I had to stop doing that.

SPEAKER_04 4:43

Yeah, it it wouldn't have taken that for me. I can hardly let someone practice an IV on me. So what question are you usually trying to answer, Joe, when you get these?

SPEAKER_00 4:51

Yeah, if I'm talking about ABGs, it it's really these days, it's only if uh I'm unable to get a good plethismography for oxygenation, if we're if we're really struggling to figure out you know where the oxygen level is at and the patient is starting to you know have some serious breathing issues, um, and I'm trying to figure out you know what the uh you know what the underlying problem is, you know, if I can get a VBG, I'll still usually start with that. Um but if we're not able to get a venous blood draw or if there's still this question of like whether they're actually hypoxic or not, that's when I'll actually go ahead and reach for the uh AMG kit.

SPEAKER_04 5:29

They start in the article with a clinical case. You've got a patient, COPD, who is unusually somulent after a procedure. Their oxygen saturation's great, 96%, but you're worried they're retaining CO2. Katie, what's what's your first test? What do you do?

SPEAKER_03 5:46

Well, now VBG. For sure. Especially if the pleth, you know, as as Joe talked about, if the pleth is reliable, seems reliable. Definitely VBG.

SPEAKER_04 5:56

And so this there, this article, the first one that we'll highlight from the journal, is is trying to answer just this question. The article is entitled Things We Do for No Reason: Arterial Blood Gas Testing to Screen for Hypercarbic Respiratory Failure. It's by Lacey and colleagues, and then obviously published in the Journal of Hospital Medicine in 2025. So the major things they they mentioned here was across several different prospective studies, they found that generally a venous CO2 cutoff or 45 or greater was a hundred percent sensitive in detecting hypercarbia that would be found on an ABG as well. So just comparing side by side, VBG, ABG. If you used a cutoff of 45 for the CO2, then you're gonna catch every hypercarbic patient that you'd also be catching with an ABG, using a definition of I think over 50 with ABGs mostly. And so the but on the other hand, looking at that's the sensitivity. The specificity was actually a little bit lower, and and there's several different trials they they looked at. But based on all of that, the argument in the study is that the VBG is basically an excellent screening test, just like we're talking about in this patient that we present. You're worried there's hypercarbic respiratory failure. The they give a little workflow algorithm, and step one is get that VBG. And then if the PCO2 is less than 45, you've effectively ruled out hypercarbic respiratory failure. If it's greater than that, then either treat clinically, or if you feel like you need more specific data, then you can get the ABG to get a little more specificity in that. Um and so they also mentioned there was a validation study that was uh prospective doing this and sat found that using VBGs to screen reduced ABG use by 29%. So a compelling argument, a meaningful outcome. How much are y'all convinced by this? And would it be changing your practice?

SPEAKER_03 8:08

Yeah, I mean I think definitely convincing. I also think the uh the people that I'm usually getting those VBGs on, it's not the subtle borderline hypercarbia, like usually these COPD exacerbations, right? It's often like greater than 100 in the 90s, 80s, 90s, and usually have other ones to compare it to as well. So you sort of understand a little bit more about the patient's baseline. And you're probably repeating it, especially on a floor patient. And so I think knowing that I'm gonna be repeating it too, and thinking about like signing someone up for multiple ABGs, if I kind of have that, you know, I think this is really what it is. It's really high. I can see if it gets better as they get better. That's you know, that kind of treatment as diagnosis aspect plays in really well with this, you know, using a BBG instead of an ABG too.

SPEAKER_00 8:57

Yeah, as as I mean, as foolish as it was to let students practice ABGs on me, experiencing that pain and that soreness, because I my risk was sore all day long, that you know, knowing that that's what my patients are going through was was valuable. I probably didn't need that particular lesson, but it was valuable to just remember, you know, this is this is you know, the these tests aren't all aren't all benign.

SPEAKER_04 9:23

Yeah, I totally agree. One thing that they did mention in here is that the pH uh between an ABG and a VBG actually correlated very well. Um there was a a really tight standard deviation or 95% um interval, and and the difference was a VBG tended to have a pH of 0.033 lower. Um and so correlates really closely. You just add 0.03, hardly anything, to your number, and and you can translate it. One thing that I think kind of having this article in my back pocket and the article at Sites does for me, though, is is gives me something to say to someone when it's like it's the ICU and they're telling me to get an ABG. So I feel like so much of ordering the ABGs is a little bit of a CYA because there's always someone at a computer or who isn't seeing the patient in real time that's gonna be either accepting or not accepting the patient, or you know, core uh Monday morning quarterbacking when they're presented on rounds the next day. And if you have this ABG that we perceive is the gold standard for the PCO2, and you can say, look at this, it was really bad. You can either, if it's me, I can get get the patient accepted by the ICU more easily, or if it's the resident or the fellow or the APP or whoever is screening patients to potentially go to the ICU, they can, even if they've seen this patient and they agree, they can have this hard and fast data point they take to the attending who's not there in the room and be like, look, this is legit. This patient really needs to come. Especially if after, you know, BIPAP for 16 hours or whatever, they look so much better and they're like, this person never should have come. Uh yeah.

SPEAKER_03 11:09

That is the beauty of life.

SPEAKER_04 11:12

Right, yeah. When it works, it works. It works, it works. Any other thoughts?

SPEAKER_03 11:18

I think my only other thing is just like commenting on how much easier it is to get the BBG to like all the nurses can grab it, you can grab it, you know, like otherwise, you know, calling respiratory or having to go find the kit yourself and take it to the you know, the lab and stuff. I think it just practically speaking is just easier to obtain too, and that matters, especially in these times when you're like, oh god, this person's pH is 6.9, which the difference between 6.9 and 6.9093 or whatever is the difference between the two is scary either way. And so I think that's that just ability to get it is really helpful too.

SPEAKER_01 11:55

So true.

SPEAKER_04 11:56

Yeah, I I agree. And and I think that's I mean, I I care about the the pain and my patient's discomfort and Joe's wrist and you know how uncomfortable the ABG is. But I I honestly I'm with you. I think the the the harm I'm more worry about for patients is the delay in care they're gonna get from, to your point, waiting for someone who has the expertise to get it. Something's clinically changed, we're almost always getting a venous blood sample, anyways, for whatever other labs. So that's already happening. And if you can just throw this on and for your PCO2, then I think that will really save delays in care. Amen to that. Katie, does this sound like a situation you've been in before? You've got a patient who came in, had UTI, maybe pilo, has E. coli bacteremia, and now they're better, and you're sitting there waiting on the susceptibilities with your fingers crossed that it's susceptible to Cypro or maybe bactrum.

SPEAKER_03 13:03

Yes. All the time. Yeah. Although not Cipro, because I hate Cipro usually, but so I really, really am praying for the Bactrom unless they have kidney disease. But yes, all the time I'm just like hoping for something.

SPEAKER_04 13:15

Oh yeah. I initially start treating them with the IV antibiotics, but then get really, really a lot better fast. And then you want to give them something P.O. And I am always just like they always want to get back to their dog.

unknown 13:27

Right.

SPEAKER_03 13:27

Their little dog that no one is watching. They always have something, you know.

SPEAKER_04 13:33

100%. Uh that's funny. Um, you have you been in the same boat with these patients, Joe?

SPEAKER_00 13:40

Absolutely. I I think I'd like to commend Katie first of all on taking the the bold stance here. All the Cypro stands are about to get into your comments, Mason.

SPEAKER_02 13:50

I know.

SPEAKER_00 13:52

But I'm I'm honestly with you. I'm uh you're I'm willing to defend myself. These days, I you know, I'm not the the biggest fan of CIPRO either, unless uh, you know, I I see that a lot more in the outpatient setting, and I'm I'm willing to leave that to the urologists for uh for their patients when I can.

SPEAKER_03 14:11

And I just really love all the articles that are telling us that we can do less time. Mason, I know a couple of your episodes focused on like pneumonia and stuff, and it's just so exciting, all of the things that we're able to like change that were just always like, nope, you have to do this, you have to do this. It's so it's just it's a very exciting, a very exciting time to be practicing.

SPEAKER_04 14:30

You you touched a little bit on this, Joe, but have y'all before before you read this article or before this article came out, were you ever doing beta-lactams or really anything oral other than Cipro or Bactram for these gram-negative bacteria? I wasn't.

SPEAKER_00 14:50

Interestingly, uh, the culture at at where I work has been shifting more towards uh transitioning to oral beta-lactams when when possible, especially the cephalosporins. On the teaching service at my shop, we we are blessed to have uh a pharmacist with the team and their residents. And so they, you know, they're they're quick to kind of help us with some of these transitions. And I think they've embraced this a little bit sooner than the hospitalist community has, um, which is why, of course, it's nice to have you know pharmacists around and have uh the interdisciplinary team like that. So I we've started doing this more, and and again, you know, now we're seeing the data to kind of bear that out, uh, which uh I've I've definitely appreciated because because now I can feel even more comfortable about it.

SPEAKER_04 15:36

So the article we're referring to is called Transition to Oral Baked Lactam Therapy and Uncomplicated Gram-negative Bacteremia, a systemic review and meta-analysis by Doran colleagues, published in, of course, the Journal of Hospital Medicine, and of course in 2025. Um and so they looked at eight retrospective cohort studies and did a meta-analysis. This captured about 7,500 patients. About 2,500 received the oral beta-lactams and were in that group. And then the other about 5,000 got the fluoroquinolone or BACTROM. And comparing these two groups, there was no statistically significant difference in 30-day mortality between the two groups, and no statistically significant difference in 30-day antibiotic failure between the two groups. And now specifically, our headline numbers were for 30-day mortality 1.89% in the beta-lactam group, 2.0% in the fluoroquinolone or bacterum group, and then for antibiotic failure, 3.42% in the beta-lactam group, 2.08 in the fluoroquinolone and bactrum group, but again, not not clinical or not statistically significant with the difference there. So since you've read this article, have you have you used it yet? Has it changed your practice at all?

SPEAKER_03 17:09

Sounds like Joe was already doing it. So it sounds like Joe is ahead of the time.

SPEAKER_04 17:13

Yeah, Joe is ahead of me, that's for sure.

SPEAKER_00 17:16

And and again, it it really comes back to, you know, having the you know, the the pharmacists and their literature, and then our infectious disease docs also sort of embrace this a little bit more. This article built on uh I was I was reading in the introduction there, they built on a 2023 study that showed no difference in 90-day mortality when you went from IV to oral antibiotics within four days of that initial culture. And so, you know, that was they didn't talk about specific antibiotics, but at least that transition could be made as, you know, within four days, sometimes sooner than that. And that's you know what we're looking at with length of stay these days.

SPEAKER_03 17:56

Yeah. And I think it's just nice to have more options too, especially as our patients get more complicated. So all the people with a potassium of 5.4 already, you know, like having something else, that's not gonna make that worse. People who've had C. diff before and are really worried about gating again, you know, like being able to have other options that are lower risk for whatever their particular comorbidities are, they're baseline confused, which is also one of the reasons I don't like Zipro. But um, right, because like, you know, all of our patients have all of these things. And so having like being able to choose for more things and kind of more specifically choose your antibiotics based on the individual patient, it just like that that ability to individualize so much more is really nice.

SPEAKER_04 18:35

And certainly encourage all the listeners to to read this full article. There is, of course, some nuance here. As Dr. Thomas was saying, they got initial IV antibiotics in in all of the studies that they looked at in this as well. And I think it was uh generally or it was four days of IV antibiotics. And then obviously, all of these studies are excluding certain patient populations, so not necessarily using this carte blanche. So questionable whether we could use it in patients that are immunocompromised or have more complicated infections, etc., but were excluded from this data set that they looked at here. And they mentioned specifically in the article that there had been a previous meta-analysis that found no different, very similar study, looked but looked at different studies, but found no difference in mortality like this study does, but did find a statistically significant difference in the clearance of the antibiotics. And they suggested in the article that that may have been due to underdosing, which is kind of telling when you look at what really is the difference between Cipro and Bactrium, particularly, and the particularly levifloxicin, and then options like cephalexin and amoxicillin, is the half-lives and the volume of distribution are the half-lives are so much shorter in the beta-lactams. And so the sort of the the thing to keep in mind and the point to take away from looking at all that is it's important that one, you figure out the right dose, and you have to also make sure you've got a patient who can take the medicines more frequently, because the the typical dosing regimen you'd expect for the cephaltium would be Q6, and for amoxicillin would be Q8, as opposed to levifloxicin, you can get away with once a day med, which may be part of the reason that it's failed in the past is because of the again, the lower half-life, you need to take it more frequently. And if you miss doses, you're not going to be treating your bacteremia. That's such a good point.

SPEAKER_03 20:43

It's hard to take a four times a day medication. And there are some circumstances where you can do the cephalexin twice a day, but this is not one that I would feel comfortable doing that. And so yeah, you really have to pick the right patient population because I could not take a medicine four times a day. I can almost guarantee you.

SPEAKER_04 21:04

Katie, you got a patient on your service, COPD, you're treating for a COPD exacerbation with 40 of PRED a day. They don't take steroids at baseline, they're not otherwise infected. A couple days into their hospitalization, what would you would have been your gut as to what the average jump in white count would be?

SPEAKER_03 21:24

Yeah, as someone who admittedly loves to blame jumps in white count on steroids and likes to repeat labs and hope that they magically got better. I really enjoy being able to kind of blame that. And I think I would blame, you know, even like several point elevations on the steroids, especially if the patient was looking the same, was getting better. I would very happily blame a a rise, a rise on the on the steroids.

SPEAKER_04 21:52

Yeah, I agree. This was a very interesting article because it put the data behind what we kind of all All obviously just sort of do off of gut and feel and we know and we talk about. And so the article is titled Elevation in White Blood Cell Count After Corticosteroid Use in Non-infected Hospitalized Patients by Sullivan et al. published in, of course, the Journal of Hospital of Medicine in 2025. This was done at 13 different health centers. They looked at a ton of patients in total, over 28,000, and then obviously only a subset of that is actually getting the steroids. And they looked at a low, medium, or high steroid group, and that's the amount of steroids they get within the first 24 hours. And they found in the low steroid group it increased by 0.3. And the medium amount of steroids, the white count increased by on average, 1.7. And for the high dose steroids, the white count increased by on average 4.84. And for me, I'll think in different steroids, but particularly at the medium to low dose is thinking more in prednisone. And so that low group would have been essentially the equivalent of 1 to 80 milligrams of prednisone. And then the medium group would be about 80 to 200, and then the high group would be essentially anything over 200 of milligrams of prednisone given in the first day. So what do y'all think? Is this something that's gonna impact how you think about patients or how you you practice going forward?

SPEAKER_00 23:35

Those ranges were wild to me. I like I you know I'm you know, I usually, you know, if it's if it's steroid or if it's COPD, it's 40 milligrams uh a day. If it's uh asthma, I'll go up to 60, maybe 80 milligrams a day. And then there are cases where I'm gonna do like the high-level uh prednisolone dosing or or whatever now as we start to give more steroids in severe pneumonia cases, some of those higher doses, but honestly, like that they called that zero to eighty low dose steroids or low category steroids. It doesn't. And then to only expect that much of a uh of an increase in the white count. I was like, ooh, I I have been ascribing too much to this.

SPEAKER_03 24:21

I had the same, I had to reread all of those ranges again. I was like, oh, because I have been similarly to you, I had sort of been that five. I was like, great, that's what I've sort of always thought. And then I was like, oh no, I don't give people that many steroids.

SPEAKER_04 24:34

At least this is about COPD exacerbation. Yeah, exactly.

unknown 24:39

Yeah.

SPEAKER_04 24:39

Yeah. One thing in sort of looking at the numbers, obviously the headline takeaway is to get really that decent jump in your white count of five, on average, you got to get to the crazy high steroids. Um, but they also appropriately shared standard deviations with us for these numbers. And I think those are interesting. So for the low group, like I said, the white count went up by 0.3, but the standard deviation was 2.7. And then for the medium group went up by 1.7, but the standard deviation 3.7. For the high group went up by 4.8, the standard deviation is 5.2. And so for all of those, the standard deviation is greater than the amount of change. And so you if this was a a normal distribution, you're getting a solid percentage, 16% or so, of patients for the high group would be that 4.84 plus the 5.2 and above that. So it would be, you know, you're given the crazy high steroids treating for whatever autoimmune thing you've got going on that you're maybe treating with all of that. Then it wouldn't be without of the realm of what we're seeing here to potentially see a 10 plus point increase in the steroids, or excuse me, in the white count. And then for the low group, which like my, you know, what doesn't feel like low of the 40 of pred, like we're talking about, we're giving COPD with that standard deviation. Yeah, maybe you're seeing a three-point increase or more in a small subset.

SPEAKER_03 26:12

And I think it does emphasize too. I mean, I think both that gestalt that both of you talked about of like, okay, if it's 18, if it goes from 15 to 18, versus if it goes from 10 to 13, like that being different and like kind of analyzing that more. And that really that importance of like talking to the patient, seeing the patient, doing your physical exam, like seeing how they look is really, really important. And why I'm glad that we're not just like only treating people from a computer. Like why we insist on free rounding for the residents, right? Like, because to make your plan for the day, like you have to be able to kind of take all of those things and synthesize them all.

SPEAKER_04 26:49

And I don't know if I said out loud that it peaked at 48 hours and then by four days the white counts had gotten down and plateaued for the super high dose, it was a little higher than their baseline. And that was pretty significant two-day bump and then comes back down, which I think also will affect how I'm interpreting these numbers.

SPEAKER_00 27:10

Yeah, they did talk about uh how if if you see that rise in the first 24 hours, or if you see like a subsequent rise in a patient who was previously the white count was coming down, uh, you know, had or had risen and had come down, those situations could be less chalked up to just the steroid dosing, and then you'd have to start investigating a little bit more.

SPEAKER_04 27:35

Let's let's talk about JHM Wrapped as as a whole a little bit, guys. Uh Joe, you gave us a good rundown at the top, but do you want to talk a little bit more about how the articles were chosen?

SPEAKER_00 27:49

The nice thing about JHM Wrapped is that it it gave us an opportunity to highlight how many different types of articles uh we have. You know, there's plenty of original research that JHM publishes, and and those are always important. Uh the things we do for no reason articles, that's something we're known for at this point. But we got to sort of highlight some of the other things that we've been doing. Our uh Keys to Innovation series, um, we looked at hospital operations. There's a big, robust pediatric hospital medicine uh, you know, cohort that um that we represented, uh, you know, I thought pretty well. You know, it's it's just that part was was a lot of fun is trying to highlight a little bit of everything that we do.

SPEAKER_03 28:32

Yeah, I totally agree. And I think kind of highlighting the articles too, we tried to do a mix of like ones like we noticed that the white blood cell count article got a lot of traction, the oral beta lacteums one, kind of the ones you pointed out, right? And that you know, the things we do for no reason always do. But also the ones like we kind of worked with our fellows, um, because we have a digital media fellowship as well as an editorial fellowship with the journal. And so an opportunity for them to like practice writing and get to kind of advocate for which articles they found really interesting as well, um, which I just thought was a fun way to kind of involve them and get them some like scholarship and highlight them as well, was that was another fun part of it.

SPEAKER_04 29:13

Um the visualizations were these specifically for JHM wrapped, or is this something y'all have started doing for multiple articles? They were super cool, definitely eye-catching. And obviously, from the fact that I do this podcast, I love just like a quick and dirty give me what I need to know, at least primer before I read an article. So tell me about those.

SPEAKER_03 29:37

Yeah, so the visual abstracts um started off, they're not that old, started off actually with a surgery journal. And they done some studies looking at articles with visual abstracts that you like put out on social media, especially, and finding that there was statistically significantly more site visits, downloads, people reading the articles when they're shared with the visual because people love visuals, right? And so JHM pretty early adopted the visual abstracts. And our sort of our philosophy is that they should give you kind of the highlights and the top parts, they shouldn't replace reading the article. Um, and then we want kind of a uniform, you know, people should recognize it and recognize that it's a JHM visual abstract, you know, so the colors are consistent, things like that. But yeah, we really try to use it to highlight articles that we think are going to be important or that we think are particularly interesting. Um and so if you get our EU table of contents, the the visual abstracts are are published in those as well as on the website. Um and then we also use it to kind of help advertise our articles on social media, kind of try to get people's interest. So I'm glad to hear that it's effective.

SPEAKER_04 30:44

Yeah. Each of you, give me one other article that was featured in JHM Rap that you think the audience should know about. Okay.

SPEAKER_03 30:51

Yeah. So one I want to highlight that I I really liked was the one about maybe liked as a weird word, I found really important, um, was the one about ED borders and who kind of is at higher risk for prolonged ED boarding. A lot of them were kind of things that make a lot of sense. People with, you know, ESBL or other precautions and they're waiting for a private room. Other things that I thought were really important and a lot sadder and kind of really speak to some of those systems issues are like the type of insurance, minoritized populations have unfortunately higher odds for prolonged ED boarding as well. And I think that's something that is important. We have to know about it to be ordered able to change those things. And so I think the fact that this article highlighted those, I think, was just really, really important for us to know.

SPEAKER_00 31:41

What about you, Dr. Thomas? For this purpose, I I want to at least mention our the point-counterpoint article that we highlighted, uh, which is what is the best strategy for developing generative AI in hospital medicine. Obviously, Gen AI is a big topic these days. It's hard to, it's, it's hard not to find it in in almost everything we do, including hospital medicine. I I've been a bit of a reluctant user on uh of of a lot of the Gen AI stuff, but this article was so interesting to at um, you know, what hospitalists are using Gen AI for. Um, the point side was using it for diagnostic reasoning, trying to decrease bias and decrease errors. And then the counterpoint, which is a little bit more of where I fall, is talking about using Gen AI to decrease the administrative burdens, talking about uses in documentation and cutting down the time spent in documentation. Uh and so I thought the the article brought up some really cool points and uh and and worth considering. Because even if you're not a big user of Gen AI, which I am not, it's worth knowing about and and knowing both the the highlights and the pitfalls. So I thought that was a great article about that.

SPEAKER_03 32:51

I think, Joe, you not being able to pick one highlights why we picked 11 top articles instead of 10 is we just can't decide. There's too many.

SPEAKER_04 33:00

Too true. I'll put a link in the show notes, but otherwise, what's the best way to access JHM Rapped?

SPEAKER_03 33:08

It's officially out in the August issue. And so our LinkedIn page, our Instagram, um, our Twitter, you can also find it'll be highlighted at some point this month uh in those places as well. So follow us.

SPEAKER_04 33:22

Yes. That's great. And well, Dr. Katie Glotz, Dr. Joe Thomas, thank you so much for being here. Thank you so much for taking your time and talking to me. And thank you to the whole uh JHM team for bringing us JHM RAPT and distilling down these articles. Uh I think it's fantastic. And I look forward to JHM RAP 2026 if we're doing it again. So do we.

SPEAKER_03 33:46

So do we. I'm looking forward to it. Thank you so much. It's an honor to be here. So thank you all.

SPEAKER_04 33:50

Awesome. Now my takeaways. First, if your patient has uncomplicated gram-negative bacteremia, is improving on IV antibiotics, and has source control, resistance to Cypro and Bactrium does not automatically mean a pick line in prolonged IV therapy. In the meta-analysis we featured, appropriately selected oral beta-lactams such as cephalexin or amoxicillin had no significant difference in mortality or recurrence compared with fluoroquinolones or bactrum. And the right patient at the right dose of beta-lactams may be appropriate. Next, when screening a patient for hypercapnia, start with a VBG. A venous CO2 below 45 millimeters of mercury can rule out significant hypercarbia and may spare the patient unnecessary pain and delays in care associated with an ABG. And steroids do raise the white blood cell count in a dose-dependent way. But on average, routine doses cause a smaller rise than you might think and peak at 48 hours after the initial dose and then downtrend. Do not automatically write off a substantial leukocytosis as just the steroids. Interpret it in the light of the dose, the timing, the magnitude, but most importantly, the overall clinical picture. Finally, check out JHM Rap for more great articles. There'll be links to all the articles in the show notes. And if this episode was useful, send it to someone else who takes care of hospitalized patients and you think would appreciate it. Thank you so much for listening. This has been Inpatient Update.