Inpatient Update

With Special Guest Dr. Bianca FarleyIn this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Bianca Farley to examine two practices driven largely by fear of rare but devastating complications:Are we correcting severe hyponatremia too cautiously? Does pharmacologic DVT prophylaxis improve outcomes that actually matter to patients? Two common hospitalist decisions. Two deeply ingrained habits. Two areas where the evidence may be more nuanced than many of us were taught. Articles & PubMed LinksSodium Correction Rates and Outcomes Among Patients With Severe HyponatremiaAnnals of Internal Medicine (2026)Retrospective cohort study of nearly 14,000 hospitalized patients with severe hyponatremia (Na ≤120 mEq/L). Compared:Slow correction: <8 mEq/L per 24 hours Moderate correction: 8–12 mEq/L per 24 hours Fast correction: >12 mEq/L per 24 hours Primary OutcomeComposite of:  90-day mortality Delayed neurologic complications Key FindingsSlow correction had the worst outcomes Moderate correction reduced adverse outcomes Fast correction reduced adverse outcomes even further Primary outcome occurred in 21% of patients overall Faster correction was associated with significantly lower risk of death or delayed neurologic events compared with slow correction. What About Osmotic Demyelination Syndrome?The traditional fear of overcorrection continues to matter, particularly in high-risk populations, but this study suggests that aggressively avoiding correction may also cause harm. Takeaway→ Avoiding overcorrection remains important. → But correcting severe hyponatremia too slowly may also worsen outcomes. → A reasonable target may be 8–10 mEq/L/day rather than reflexively aiming for the lowest possible correction rate.Pubmed: https://pubmed.ncbi.nlm.nih.gov/41587479/Pharmacologic Thromboprophylaxis in Medical InpatientsJAMA Network Open (2026)Systematic review and network meta-analysis of 22 randomized trials involving 43,840 medical inpatients. Compared:Low-molecular-weight heparin (LMWH) Unfractionated heparin (UFH) Direct oral anticoagulants (DOACs) No pharmacologic prophylaxis Key FindingsSymptomatic VTEBaseline risk without prophylaxis:1.7% at 90 days LMWH:Reduced symptomatic VTE RR 0.68 (95% CI 0.49–0.94) Clinically Relevant VTELMWH RR 0.57 DOAC RR 0.58 UFH RR 0.66 MortalityNo mortality benefit with any regimen. Major BleedingDOACs increased major bleeding UFH increased major bleeding LMWH showed no statistically significant increase in major bleeding. InterpretationPharmacologic prophylaxis reduces VTE events, but:Absolute VTE risk is relatively low Mortality is unchanged Bleeding risk must be considered Patient selection matters Takeaway→ DVT prophylaxis works, but mostly by preventing relatively uncommon events. → Benefits are greatest in appropriately selected high-risk patients. → LMWH appears to offer the best balance of efficacy and safety.Pubmed: https://pubmed.ncbi.nlm.nih.gov/42138924/Practice-Changing TakeawaysSevere HyponatremiaFear of osmotic demyelination has likely pushed many clinicians toward overly conservative correction. Emerging evidence suggests slow correction may itself be harmful. Consider targeting meaningful correction rather than simply avoiding overcorrection. DVT ProphylaxisPrevents VTE. Does not appear to reduce mortality. Absolute benefit is smaller than many clinicians assume. Risk-benefit assessment remains essential. Clinical PearlsThe most feared complication is not always the most common complication. Many hospital practices persist because of rare catastrophic outcomes rather than aggregate patient outcomes. The best question is often not "Can this happen?" but "What happens most often?" Bottom LineIf you change nothing else this week:Reconsider whether your severe hyponatremia patients are being corrected too slowly. Remember that DVT prophylaxis prevents clots, but has never clearly been shown to save lives in general medical inpatients. Sometimes the greater danger isn't doing too much—it's doing too little.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

With Special Guest Dr. Ernest MurrayIn this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Ernest Murray to challenge two common antibiotic reflexes in hospital medicine:Do hospitalized patients with community-acquired pneumonia really need 5–7 days of antibiotics?Do we need to panic about QT prolongation every time we prescribe ciprofloxacin?Two everyday prescribing decisions. Two long-standing assumptions. Two areas where the evidence may support a more precise approach. Articles & PubMed Links3–4 Days vs ≥5 Days of Antibiotics for Community-Acquired PneumoniaAnnals of Internal Medicine (2026)Target trial emulation using >55,000 CAP hospitalizations across 60+ hospitals.Compared:3–4 days antibiotics vs ≥5 days antibioticsAfter strict inclusion/exclusion criteria, ~5,600 clinically stable patients were analyzed.Excluded: Immunocompromised patients  Severe chronic lung disease  Drug-resistant organisms  ICU-level illness  COVID-19 Primary Outcomes 30-day mortality  Readmissions / urgent visits  Antibiotic-associated C. difficile Key Findings No significant difference in:  Mortality  Readmissions  Urgent visits  C. difficile infection InterpretationIn carefully selected, clinically stable CAP patients: → 3 days may be enoughpubmed: https://pubmed.ncbi.nlm.nih.gov/41974005/Ciprofloxacin and QTc ProlongationJournal of Antimicrobial Chemotherapy (2026)Prospective study evaluating QTc before and after standard-dose ciprofloxacin. Baseline ECG obtained  Repeat ECG after reaching steady-state ciprofloxacin levels Key Findings No statistically significant change in QTc  Mean QTc remained essentially unchanged (~415 ms)  Patients with significant QT prolongation had:  Multiple competing risk factors  Concurrent QT-prolonging medications  Electrolyte abnormalities InterpretationFor most stable patients: → Ciprofloxacin alone does not meaningfully prolong QTcThe real danger appears to be: Polypharmacy  Electrolyte derangements  Critical illness  Multiple simultaneous QT-prolonging factors pubmed: https://pubmed.ncbi.nlm.nih.gov/41628197/Practice-Changing TakeawaysCommunity-acquired pneumonia: Stable patients may only need 3 days of antibiotics  “Minimum 5 days” is no longer absolute dogma Ciprofloxacin: QT concern should be contextual, not reflexive  Don’t deny patients effective oral therapy solely out of generalized QT fear Clinical Pearls Antibiotics may not need to “eradicate” infection completely — just shift the balance enough for the immune system to finish the job  Lung microbiome preservation may become increasingly important in future stewardship strategies  Most dangerous QT events are multifactorial, not caused by a single medication in isolation  Ciprofloxacin remains an extremely valuable oral option for:  Gram-negative bacteremia  Pseudomonas coverage  Avoiding PICC lines and prolonged IV therapy Bottom LineIf you change nothing else this week: Consider stopping CAP antibiotics after 3 days in carefully selected stable patients  Use ciprofloxacin thoughtfully — but don’t reflexively fear the QTcSupport the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

With Special Guest Dr. Adam JaffeIn this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Adam Jaffe to tackle two high-impact clinical questions:Is there a clear winner among DOACs? Who actually benefits from steroids in community-acquired pneumonia? Two common decisions. New data. Practice-changing implications. Articles & PubMed LinksApixaban vs Rivaroxaban for VTE (Head-to-Head RCT)New England Journal of Medicine (2026)Randomized trial (n=2,760) comparing:Apixaban vs Rivaroxaban Population:Acute VTE Excluded: active cancer, extreme obesity, other anticoagulation indications Key Findings↓ Clinically significant bleeding with apixaban ~54% relative risk reduction NNT ≈ 27 ↓ Major bleeding (0.4% vs 2.4%) No difference in: Recurrent VTE Mortality InterpretationSame efficacy Less bleeding with apixaban Takeaway→ For new starts: Apixaban is the preferred DOACpubmed: https://pubmed.ncbi.nlm.nih.gov/41812192/Corticosteroids in Community-Acquired Pneumonia (IPD Meta-analysis)LancetLarge meta-analysis (n=3,224 across 8 RCTs)Compared:Steroids vs Placebo Primary Outcome: 30-day mortalityAbsolute risk reduction: 2.2% NNT = 46 🔑 The Key Insight: CRP MattersWhen stratified by inflammation:CRP >200Mortality: 13% → 6% Absolute risk reduction ≈ 7% NNT ≈ 14 CRP <200No mortality benefit Other Findings↑ Hyperglycemia (expected) ↑ Readmissions (7% vs 3.7%) No clear signal that severity scores (PSI) identify benefit InterpretationSteroids are not for everyone Benefit appears driven by high inflammatory states Takeaway→ Consider steroids in CAP only if CRP is markedly elevated (~>200) → Routine use in all pneumonia is not supportedpubmed: https://pubmed.ncbi.nlm.nih.gov/39892408/Practice-Changing TakeawaysDOACs: Apixaban > rivaroxaban for bleeding Same clot prevention → choose apixaban for new starts Pneumonia: Steroids may reduce mortality — but only in the right patient CRP can help identify who benefits Clinical PearlsThe difference between DOACs is no longer “vibes” — we now have head-to-head data Most steroid benefit in pneumonia appears inflammatory-driven, not severity-driven CRP — often ignored — may actually guide meaningful decisions here Bottom LineIf you change nothing else this week:Start apixaban for new VTE patients In pneumonia, check a CRP — and consider steroids if >200 Fewer bleeds. Smarter steroids. Better outcomes.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

With Special Guest Dr. Austin WhiteIn this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Austin White to tackle two everyday controversies that affect nearly every admission:Asymptomatic inpatient hypertension — are PRN antihypertensives helping… or harming? Antibiotics for pneumonia with a positive viral panel — do these patients actually benefit? Practical take-homes, real-world night shift scenarios, and what to change on rounds tomorrow. Articles & PubMed Links:As-Needed Blood Pressure Medication and Adverse Outcomes in VA HospitalsJAMA Internal Medicine (2025)Retrospective cohort of hospitalized patients comparing:Received PRN antihypertensives vs No PRN treatmentKey Findings ↑ Acute kidney injury (HR ~1.23)  ↑ Rapid BP drops >25% (HR ~1.5)  ↑ Composite outcome (MI, stroke, death) (HR ~1.6) IV meds worse than oral Interpretation Treating asymptomatic inpatient hypertension is associated with harm, not benefit  Likely mechanism: overcorrection → hypoperfusionTakeawayFor asymptomatic hypertension, especially overnight: → Don’t reflexively treat the number → Focus on symptoms and underlying causePubmed: https://pubmed.ncbi.nlm.nih.gov/39585709/ Antibiotics for Pneumonia with Positive Viral TestingMulticenter Retrospective Study (2015–2024)Compared:Minimal antibiotics (0–1 day) vs Standard CAP treatment (5–7 days)In patients with: Positive viral assay  Clinical pneumonia (hypoxia, tachypnea, imaging) Key FindingsNo difference in:  Mortality  ICU admission  Length of stay  No clear harm signal either Interpretation Many patients with “pneumonia” + viral panel likely have pure viral illness Routine antibiotics do not improve outcomesTakeaway→ If viral etiology fits the clinical picture, don’t routinely continue antibioticsPubmed: https://pubmed.ncbi.nlm.nih.gov/41378862/ Practice-Changing TakeawaysHypertension: Treat the patient, not the number  PRN antihypertensives for asymptomatic BP may cause harm Viral pneumonia: Positive viral panel + consistent story → hold antibiotics Reassess if clinical course worsens Both topics highlight: → We often overtreat out of habit, not evidenceClinical Pearls from the Episode The body tolerates transient high BP better than rapid drops  Overcorrection → ↓ cerebral perfusion → bad outcomes  Viral infections (even “mild” ones like rhino/adenovirus) can cause severe illness Antibiotic stewardship = patient safety, not just resistance Bottom LineIf you change nothing else this week: Stop reflexively treating asymptomatic inpatient hypertension  Stop reflexively continuing antibiotics for viral pneumonia Less intervention. Better outcomes.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

With Special Guest Dr. Emily ReamsIn this special episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Emily Reams to break down the most practice-changing takeaways from SHM Converge 2026.No fluff — just what you can start doing on rounds tomorrow.Topics include: Flu shots in heart failure — real mortality benefit  Stopping aspirin in patients on DOACs  Anticoagulation in AFib despite fall risk  Naltrexone for alcohol use disorder — start inpatient  Phenobarbital for withdrawal — coming soon  Metformin in the hospital — dogma challenged  Transfusion thresholds in MI  “Things We Do for No Reason” highlights Practical take-homes and what to actually change this week.Practice-Changing Highlights💉 Flu shots in heart failure NNT ≈ 17 for death/readmission → Vaccinate before discharge during flu season💊 Stop aspirin with DOACs ↑ bleeding and mortality without benefit → Stop aspirin ~6–12 months post-stent (most patients)🧠 AFib + fall risk Benefit >> risk (would need >450 falls/year to offset) → Don’t withhold anticoagulation for falls alone🍺 Alcohol use disorderNaltrexone: start before discharge → ↓ cravings, ↓ readmissions Phenobarbital: increasing use, likely future standard 💊 Metformin inpatient May be safe in select patients → Consider if GFR ≥30 and no lactic acidosis🩸 Transfusion in MI Target Hgb ~10 may reduce mortality → Evolving — keep on radar💊 Anticoagulation updates Apixaban preferred over rivaroxaban  Reduce dose after 3–6 months for VTE → Reassess dosing routinelyBig Picture Biggest wins = simple changes Often: stop meds or use basics better Hospitalists have high-impact touchpoints If You Change Nothing Else This Week Give flu shots in heart failure  Stop aspirin in DOAC patients (when appropriate)  Anticoagulate AFib despite fall risk  Start naltrexone before discharge Small changes. Massive reach. Real impact.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

Episode 5: De-escalating Sepsis Antibiotics & When to Pull the IV w/ Nicholas Linde, PAWith Special Guest Nicholas Linde, PAIn this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist PA Nick Linde to tackle two everyday decisions that impact nearly every inpatient service:De-escalating broad-spectrum antibiotics in sepsis — is it safe to stop vancomycin and zosyn earlier than we think? Routine peripheral IV use — are we leaving IVs in too long and causing harm? Practical take-homes, real-world cases, and what to change on rounds tomorrow.Articles & PubMed LinksAntibiotic De-escalation in Adults Hospitalized With Community-Onset SepsisJAMA Internal Medicine (2026)Compared:Continue broad-spectrum antibiotics beyond day 4 vs De-escalate at day 4 Key FindingsNo difference in 90-day mortality (OR ≈ 1.0) Shorter hospital length of stay  ~1 day shorter (MRSA de-escalation) ~2 days shorter (pseudomonal de-escalation) No clear harm signal with de-escalation TakeawayIn clinically improving patients with negative or non-MDR cultures, early de-escalation at day 4 is safe and reduces hospital stay.Pubmed: https://pubmed.ncbi.nlm.nih.gov/41428290/ Things We Do for No Reason™: Routinely Maintaining Intravenous Access in Hospitalized PatientsJournal of Hospital Medicine (2026)Key Points~25% of inpatient IVs are idle (not in use) Peripheral IVs contribute to morbidity: ~20% of MSSA bacteremia When to RemoveNo IV medications or fluids needed Clinically stable patient Oral alternatives available When to KeepHigh risk of decompensation Anticipated procedures or IV contrast Ongoing electrolyte replacement or IV therapy TakeawayPeripheral IVs are not benign — if you’re not using it, seriously consider removing it.Pubmed: https://pmc.ncbi.nlm.nih.gov/articles/PMC12865233/ Practice-Changing TakeawaysSepsis: At day 4, reassess. If cultures are negative and patient improving, de-escalate broad-spectrum antibiotics. IVs: “Use it or lose it.” Idle IVs carry real risk — don’t leave them in by default. These are high-frequency decisions → small changes = big impact.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

Episode 4: Faster Hypernatremia Correction & Long-Acting Antibiotics for Staph BacteremiaWith Special Guest Dr. Kevin BakerIn this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Kevin Baker to discuss two studies that challenge long-held dogma in inpatient medicine:Faster correction of hypernatremia — is the traditional “go slow” rule actually harming patients?Dalbavancin for Staph aureus bacteremia (DOTS Trial) — can two long-acting antibiotic injections replace weeks of IV therapy and PICC lines?Practical take-homes, real-world discussion, and what to change on rounds tomorrow (with a couple of bourbons).Articles & PubMed LinksClinical outcomes of early fast compared to slow sodium correction rate in adults with severe hypernatremia: A comparative effectiveness studyJournal of Critical Care (2025)Key FindingsFaster correction associated with lower 30-day mortalityShorter ICU length of stayShorter hospital length of stayNo signal for neurologic complications from rapid correctionSupporting data from prior studies:2023 JAMA observational cohort Faster correction associated with lower mortality No neurologic complications reported2025 Journal of Critical Care meta-analysis Faster correction not associated with worse outcomesTakeawayFor adult hypernatremia, especially in critically ill patients, more aggressive correction appears safe and may improve outcomes.Pubmed: https://pubmed.ncbi.nlm.nih.gov/41240509/Dalbavancin for Treatment of Staphylococcus aureus Bacteremia: The DOTS Randomized Clinical TrialJAMA 2025Compared:Standard Therapy4–8 weeks IV antibioticsCefazolin / anti-staphylococcal penicillin (MSSA)Vancomycin or daptomycin (MRSA)vsDalbavancin Strategy1500 mg IV day 11500 mg IV day 8Long-acting lipoglycopeptide with ~14-day half-life, allowing completion of therapy without PICC lines.PopulationComplicated Staph aureus bacteremiaKey ResultsClinical efficacy:Dalbavancin: 73%Standard therapy: 72%Microbiologic success:Dalbavancin: 98.8%Standard therapy: 96.3%Met criteria for non-inferiority.TakeawayFor selected patients with cleared Staph aureus bacteremia, two doses of dalbavancin may replace weeks of IV antibiotics and PICC lines.Potential advantages:Avoids central line complicationsSimplifies discharge planningUseful in patients with difficult social situations or IV access concernsPubmed: https://pubmed.ncbi.nlm.nih.gov/40802264/Practice-Changing TakeawaysHypernatremia: Faster correction appears safe in adults and IMPROVES mortality.Staph bacteremia: Long-acting dalbavancin offers a PICC-free alternative for completing therapy in selected patients.Hospital medicine continues to move toward shorter and simpler antibiotic strategies.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

In this episode of Inpatient Update, Dr. Mason Turner is joined by Dr. Andres Ospina, fellow hospitalist, to discuss two recent trials with immediate impact on hospital practice:Aspirin plus anticoagulation in chronic coronary disease (AQUATIC Trial) — does keeping aspirin help or harm when long-term anticoagulation is started?Seven vs fourteen days of antibiotics for bloodstream infection (BALANCE Trial) — can we safely cut bacteremia treatment in half?Practical take-homes, clear links to the evidence, and what to change on rounds tomorrow.Articles & PubMed LinksAspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation (AQUATIC Trial)New England Journal of Medicine (October 2025)Key Findings:Higher morbidity and mortality with dual therapy (HR 1.53)Bottom Line: In stable CAD >6 months from revascularization, if anticoagulation is started, stop the aspirin.Pubmed: https://pubmed.ncbi.nlm.nih.gov/40888725/Antibiotic Treatment for Bloodstream Infection (BALANCE Trial)New England Journal of Medicine (November 2024)Multicenter, randomized, non-inferiority trial (n≈3,600)Bottom Line: In uncomplicated bacteremia with source control and no severe immunocompromise, 7 days is non-inferior to 14.Pubmed: https://pubmed.ncbi.nlm.nih.gov/39565030/Practice-Changing TakeawaysStable CAD + new anticoagulation? Stop aspirin if >6 months from PCI/CABG.Uncomplicated bacteremia? Seven days of antibiotics is sufficient in most cases (excluding Staph aureus and deep-seated infection).Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

In Episode 2 of Inpatient Update, your host, Dr. Mason Turner, breaks down three studies that could change what you do on rounds tomorrow:Phenobarbital for alcohol withdrawal — fewer admissions and shorter ED stays during the IV lorazepam shortage natural experiment.Conservative dialysis in AKI requiring RRT (LIBERATE-D) — less routine dialysis, more kidney recovery?Postoperative transfusion thresholds in high–cardiac-risk patients (TOP Trial) — is 7 still enough?Articles & PubMed LinksFewer Admissions, Shorter Stays: Phenobarbital Use for Alcohol Withdrawal in the Emergency Department Academic Emergency Medicine (2025) PubMed: https://pubmed.ncbi.nlm.nih.gov/41147831/A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury (LIBERATE-D Trial) JAMA ( 2026) PubMed: https://pubmed.ncbi.nlm.nih.gov/41201895/Liberal or Restrictive Postoperative Transfusion in Patients at High Cardiac Risk: The TOP Randomized Clinical Trial JAMA (2025) PubMed: https://pubmed.ncbi.nlm.nih.gov/41205227/REACH OUT:Have insight into inpatient medicine? Article suggestion? Interested in being a guest?Email or DM me. Follow and subscribe wherever you listen so you never miss the next update.Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/

In this pilot episode of Inpatient Update, your host, Dr. Mason Turner, breaks down three clinically relevant studies that could change how you practice tomorrow on the wards:Pre-ERCP antibiotic prophylaxis — does it reduce post-procedure infections in biliary obstruction?Reduced-dose apixaban after 6 months in cancer-associated VTE — noninferior and potentially safer?Early initiation of beta-blockers in cirrhosis with uncomplicated ascites — early signals of benefit.Practical take-homes, clear links to evidence, and what to tell your team on rounds.Articles & PubMed LinksIs Antibiotic Prophylaxis Warranted in All Patients With Biliary Obstruction Undergoing Endoscopic Retrograde Cholangiopancreatography?: A Systematic Review and Meta-Analysis PubMed: https://pubmed.ncbi.nlm.nih.gov/40961256/ Extended Reduced-Dose Apixaban for Cancer-Associated VTE (API-CAT) PubMed: https://pubmed.ncbi.nlm.nih.gov/40162636/ Efficacy and Safety of Carvedilol in Cirrhosis Patients With New-Onset Uncomplicated Ascites Without High-Risk Esophageal Varices (CARVE-AS Trial) PubMed: https://pubmed.ncbi.nlm.nih.gov/40689908/ Support the showWant the cited articles and key takeaways? Join the email list:https://subscribe.inpatientupdate.com/