#482 Recap from SHM #Converge25

May 5, 2025 | By Meredith Trubitt

Audio

Video

Transcript available via YouTube

Highlights and Pearls from SHM’s Annual Meeting

We recap the top pearls for the hospitalist from #SHM #Converge25 hitting updates in GI, stroke, anticoagulation, perioperative medicine, artificial intelligence, and more. 

Note: There is no CME for this episode, but visit curbsiders.vcuhealth.org to claim credit for past episodes.

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Show Segments

• Intro
• Care of the Patient Experiencing Homelessness
• Updates in GI
• Delirium
• Adaptive Leadership
• Transgender Health
• Capacity Assessment
• Heart Failure
• Care of the Transplanted Kidney
• Precipitated Withdrawal
• IV contrast
• Alcohol Withdrawal
• MRSA Nares Swabs
• Bugs, Bite, and Fever
• Perioperative Medicine 
• Parkinson’s Disease
• Stroke 
• Outro

Disclosures

The Curbsiders report no relevant financial disclosures. 

SHM Converge 2025 Recap

Care for the Patient Experiencing Homelessness

• In 2023, 970,806 people in the United States experienced homelessness. Men experience homelessness more often than women, but this gap has been closing over recent years (National Alliance to End Homelessness, 2023)
• Among people experiencing homelessness, the most common reasons for hospitalization are: 1) psychiatric disorders, 2) injury, 3) cardiac disorders (Rollings, 2022)
• Hospitalization can be an opportune time to address other underlying issues like nutrition and mobility. Be mindful of these topics and address them early and often through asking why and exploring individual barriers. Consider hospital-related problems such as agitation/behavioral outbursts, stigma, and documentation of “AMA” discharges (Alfandre, 2017). Lastly, the lack of surrogate decision-makers may further complicate care. 

Updates in GI

Pancreatitis

• Almost all the scorpion envenomation causes of pancreatitis happen in Brazil (10,000/year) or northern Venezuela – caused by Tityustoxin from the Tityus serrulatus scorpion.
• Lactated ringers is superior to normal saline for acute pancreatitis (Lee 2021, Aziz 2021), and the WATERFALL trial suggested a moderate fluid resuscitation strategy was safer than an aggressive one (de-Madaria 2022). Check out episode #367 Weekend Warriors, Fluids for Acute Pancreatitis, Colonoscopy Screening & Mortality, and SPRINT trial Revisited (Hotcakes) for an in-depth discussion of WATERFALL.
• When considering the timing of cholecystectomy in acute biliary pancreatitis, 18% of patients who had cholecystectomy delayed for any reason (by a median of 19-58 days) were readmitted for biliary events, compared with ZERO readmissions for recurrent biliary events if cholecystectomy was performed on the index admission (Van baal 2012).

Ulcerative Colitis

• Among all patients with ulcerative colitis, about 25% will require hospitalization for severe symptoms. Of those, approximately 40% will require colectomy by their second hospitalization (Le Berre, 2023).
• Low serum cholesterol or magnesium affect the efficacy of cyclosporine. Obtain an initial magnesium level and lipid panel and consider infliximab over cyclosporine if abnormal.
• It is also helpful to obtain a quantiferon gold and hepatitis B serologies on admission to guide later treatment decisions.

Delirium

• Think of delirium as acute brain dysfunction. Just as with other acute organ injury, long-term effects may follow (in this case, dementia). 
• Delirium (especially hypoactive delirium), is underdiagnosed in the intensive care unit, and very likely on the inpatient ward as well (Spronk, 2009).
• In the hospitalized patient, use the mnemonic “TADA” (tolerate, anticipate, don’t agitate) to guide delirium prevention and management. Ensure your patient is safe and has adequate supervision, de-escalate unnecessary “tethers” such as catheters, oxygen, and IV lines, and partner with nursing staff to develop management plans with the goal of minimizing further agitation (Flaherty, 2011). 
• More on delirium from episode 375!

Adaptive Leadership

• Emotional intelligence is more important than technical skills or IQ (Harvard Business Review).
• The five components of emotional intelligence are self-awareness, self-regulation, motivation, empathy, and social skill.

Transgender Health

• Transgender patients experience significant discrimination, even within the healthcare system: 48% of transgender people have personally experienced discrimination in healthcare environments, and 1/4 avoided clinical care due to mistreatment (James 2024).
• If misgendering happens, Dr. Khanijow suggests the following four-step approach: Thank the patient for the correction, correct yourself, apologize succinctly, and move on with the visit or the patient’s care.
• Additionally, when a transgender patient is admitted to the hospital, it is considered standard of care for the patient to have a private room. If they have a shared room, this should be based on the patient’s gender identity, not their gender assigned at birth.
• If a transgender patient on supplemental estrogen develops a venous thromboembolism, consider temporarily holding estrogen or switching to a transdermal formulation, which are less thrombogenic (Deustch 2016).
• The speaker has a recent JHM publication on the topic here.

Rapid Responses

Check out our previous episodes on rapid response pearls: #350 Rapid Response Series: Acute Hypoxemia and #473 Rapid Response Series: Narrow Complex Tachyarrhythmias with Dr. Noble Maleque.

Capacity Assessment

• As many as 26% of general internal medicine patients may lack decision-making capacity; this figure is as high as 55% for patients with moderate dementia (Barstow, 2018).
• 50% of clinicians fail to recognize when a patient lacks capacity; and one-third of assessments are incorrect (Barstow, 2018).
• Considering treatment over a patient’s objections requires clear imminent/serious harm, relative certainty of benefit, and a favorable benefit > risk analysis. Lack of assent may complicate treatment of chronic problems. 

Heart Failure Management

• The STRONG-HF trial (discussed on a few prior episodes, including #393) established that delaying initiation of GDMT therapy by even a few weeks leads to excess mortality. Starting patients on all indicated drug classes before discharge from a hospitalization for an acute heart failure exacerbation is an urgent priority.
• The presenters like to start with an ARNI on admission because you get some vasodilation from this and it can improve diuresis (expert opinion). 
• Then they start an MRA given the mild diuretic effect and potassium sparing effect (expert opinion).
• They typically start an SGLT2i third (expert opinion).
• The one recommendation that is clear from the guidelines is waiting until patients are euvolemic to start a beta blocker – they are much better tolerated then (Heidenreich, 2022).
• For HFrEF, all 4 pillars of GDMT get a class I recommendation from ACC/AHA, and lead to an impressive cumulative risk reduction in all-cause mortality: RRR 72.9%, ARR 25.5%, NNT 3.9 over 4 years.
• For HFpEF, SGLT2i’s get a class I recommendation from the ESC, and only class 2a from ACC/AHA. RAASi and MRAs both get class 2B, and BBs are not recommended unless patients have a separate indication for them.
• The SUMMIT trial of tirzepatide and STEP-HFpEF trial of semaglutide both yielded impressive results, but recommendations from these haven’t made it into guidelines yet – stay tuned for future updates. 

Care of the Transplanted Kidney

• Renal transplantation is the most common solid organ transplant in the world!
• Causes of hypertension after transplant include donor factors (age, essential hypertension), graft factors (delayed graft function, rejection), immunosuppression (calcineurin inhibitors or steroids), renal artery stenosis, among others.
• Causes of AKI in the transplanted kidney include common pre-renal, intrinsic and post-renal causes, but also consider causes related to the transplant itself. Some examples:
  • Pre-renal AKI may be caused by include calcineurin inhibitors or renal artery stenosis. 
  • Post-renal AKI may be caused by hydronephrosis from ureteral stricture (which may require stenting or ureteral reimplantation)
  • Intrinsic AKI may be caused by many things including rejection, BK nephropathy, thrombotic microangiopathy, recurrent disease (e.g. FSGS), venous thrombosis, and others.

MedTed 2.0

• While fentanyl is a  short-acting opioid agonist, it is lipophilic and will collect in the adipose tissue resulting in increased blood levels over longer periods of time (Providers Clinical Support System, 2023). 
• Therefore, use the clinical opioid withdrawal scale to determine appropriateness for initiating buprenorphine, since it can precipitate withdrawal. 
• Historical concern about using IV contrast in patients with an AKI or CKD has not led to identification of a convincing causal relationship, and forgoing a necessary contrast study could itself be detrimental (Coleman, 2025). 

Management of Alcohol Withdrawal Syndrome

• Per the American Society of Addiction Medicine (ASAM) 2020 guidelines, most patients with mild-moderate withdrawal can be managed in an outpatient setting (only ~10% require inpatient treatment).
• The most reliable predictor of whether a patient is going to develop severe withdrawal (seizure or withdrawal delirium) is whether the patient has previously experienced severe withdrawal (Goodson 2014, Wood 2018). Risk assessment tools also exist for this purpose. (PAWSS score).

The data for scheduled versus symptom-triggered benzodiazepines originated over 30 years ago. The hallmark study (Saitz 1994) was in a 1994 randomized double-blind controlled trial and included 101 patients admitted to the Manchester VA Medical Center Alcohol Detoxification Unit, who were randomized to PRN or scheduled plus PRN chlordiazepoxide. The PRN group required less drug and shorter treatment duration with similar outcomes, and many patients in the symptom-triggered group did not require any medication. 

Benzodiazepines have many adverse effects, and non-benzodiazepine agents including anticonvulsants (carbamazepine, valproic acid, gabapentin) and alpha-2 adrenergic agonists (clonidine, guanfacine, dexmedetomidine) are useful adjuncts or alternatives. 

• A recent observational study on a trauma surgery service implemented a benzodiazepine-sparing pathway using clonidine and gabapentin to prevent and treat alcohol withdrawal syndrome. This study showed that their protocol is safe, reduces the daily maximum CIWA-Ar, and significantly decreases the need for benzodiazepines (McCullough 2024). 
• Implementation of a different benzodiazepine-sparing order set was associated with decreases in benzodiazepine exposure, intensive care unit use, and length of stay (Smith 2022).
• However, both of these studies are observational, and warrant further studies to draw definitive conclusions. 

For patients with evidence of severe alcohol withdrawal, ASAM recommends considering frontloading patients when CIWA >19. While the ASAM 2020 guidelines advise caution with phenobarbital due to potential adverse effects like respiratory depression, several observational studies (Malone 2023, Hundert 2024, Kessel 2024) failed to identify a significantly higher risk of respiratory depression with phenobarbital. There are still no large randomized controlled trials on phenobarbital versus benzodiazepine therapy in this population.

MRSA Nasal Swabs 

MRSA prevalence varies geographically. Build your pretest probability using local data if possible, as well as MRSA risk factors.

For community acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP), a negative nasal MRSA PCR swab excludes MRSA unless the pretest probability is high (2019 ATS/IDSA Community Acquired Pneumonia (CAP) Guidelines).

• A CID meta-analysis demonstrated that the pooled sensitivity and specificity for MRSA CAP and healthcare-associated pneumonia (HCAP) were 85% and 92%, respectively, with a positive likelihood ratio of (LR) of 10.8 and negative LR of 0.16 (Parente 2018).
  • If the patient has a low pretest probability + negative MRSA swab = stop vancomycin
  • If the patient has a high pretest probability + negative MRSA swab = continue vancomycin, wait for cultures at 48-72 hours
• Exercise caution in patients with recent MRSA nasal decolonization, MRSA infection within 30 days, structural lung disease, and critically ill patients (consider de-escalation at 48-72 hours if sputum/blood cultures also negative)
• Always follow the clinical context as well: if the patient is improving on a current therapy, keep it.

In the most recent 2016 IDSA/ATS HAP/VAP Guidelines, there is no clear recommendation to navigate MRSA PCR swabs in patients with VAP. A negative MRSA swab in VAP does not reliably exclude MRSA (negative LR 0.63). The MRSA swab also doesn’t help much for de-escalating antibiotics in skin and soft tissue infections: positive LR of 9.4, negative LR of 0.56. The most recent SSTI guidelines are from 2014 (IDSA 2014). 

An exciting trial on the horizon is the STOP-Vanc trial, which will provide the first RCT data regarding the use of MRSA swabs to guide antibiotic de-escalation.

Bugs, Bites, and Fever

• Dengue fever, Chinkungunya and Zika Virus are all arboviruses, and can present similarly. Some unique characteristics of each are listed below, but may not be present in every case, so you still need to take in the entire clinical picture (Pan American Health Organization, 2022).
  • Dengue: the majority will be asymptomatic, but sometimes have serositis 
  • Chinkungunya: the majority will be symptomatic, and arthritis is a main complaint 
  • Zika: adenopathy and pharyngitis are common
• You can spray Permethrin on your clothes to decrease the spread of vectors, and while it degrades over time, it can be effective for short-term protection. (Achee, 2019).

Perioperative Medicine

• A lot of nuance and context to this topic, but highlights from many of the talks were highlighted in recent perioperative episode #475.
• Digital Health Tools exist and can be used as part of the pre-operative risk assessment. Specifically, step counts seem to be helpful in ascertaining functional status. Other tools highlighted in this session include cognitive training apps, prehabilitation via coaching apps, and extended reality for pain and anxiety; all of which require more research and evaluation.  

Parkinson’s Disease

• Parkinson’s Disease has a prodromal phase that can last 1-2 decades before diagnosis. Symptoms can include GI symptoms like constipation; autonomic dysfunction, sensory symptoms like non-specific pain, impaired olfaction, and visual abnormalities; sleep disorders (especially REM sleep behavior disorder), depression, and cognitive impairment (Castilla-Cortazar, 2020).
• Hospitalized patients with Parkinson’s disease typically have late-stage disease, at which time dysphagia can become difficult to manage. If a feeding tube is necessary, short-acting medications to control symptoms can be crushed. Use expertise of pharmacy and neurologist to optimize therapeutics when dysphagia becomes limiting (expert opinion).
• Symptoms of orthostatic hypotension: dizziness, lightheadedness, syncope, headache, cognitive slowing, orthostatic dyspnea, angina, visual disturbance due to retinal hypoperfusion, neck and shoulder pain due to muscle hypoperfusion, generalized weakness, falls, fatigue, nausea, and increased risk for fractures and head trauma (Neurotorium, 2025).

Stroke

• Dr. McCall framed the talk in terms of phases of stroke care from hyper-acute phase to chronic phase with the focus in the hyper-acute phase on rapid diagnosis and intervention. 
• Based on studies like NINDS trial (National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995) and ECASS-3 (Hacke, 2008), guidelines have historically recommended TPA administration within 4.5 hours after a patient was last seen normal. 
• More recently, studies like NOR-TEST (Logallo, 2017) and EXTEND-IA TNK (Campbell, 2018) compared TPA to tenecteplase. In NOR-TEST there was no difference in adverse events, mortality, or 90 day independence, and EXTEND-IA TNK there was higher incidence of reperfusion and improved functional status when treated within 4.5 hours. 
• Currently, studies have examined broadening the timeline for TPA to 24 hours, with TIMELESS in 2023 and TRACE-III in 2024, which showed only marginal benefit but with no increase in harm, suggesting certain subgroups may benefit from TPA beyond 4.5 hours (expert opinion). 
• Zero Degree Head Positioning was recently studied, and data from the ZODIAC trial has been presented at major stroke conferences. The study compared zero degree head positioning to 30 degree head positioning in patients who have a large vessel occlusion awaiting thrombectomy. The zero degree positioning group had significantly less early neurologic deterioration and lower 90-day mortality, with no increase in symptomatic ICH or aspiration pneumonia. (https://newsroom.heart.org/news/position-of-stroke-patients-head-before-surgery-may-improve-neurological-function)

Goal

Listeners will  be served delicious knowledge food from SHM’s #Converge25

Learning objectives

After listening to this episode listeners will…  

1. Review key practice-changing pearls

Citation

Trubitt M, Amin M, Coleman C, Brooks M, O’Glasser A, Ganatra RB, Williams PN, Watto MF. “#482 Recap from SHM #Converge25”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast Final publishing date May 5, 2025.