Episode 180: Pediatric Hip PainFuture Dr. Pena-Brockett explains the differential diagnosis in a 14-year-old patient who has a new onset of left hip pain. Dr. Arreaza adds comments and explains toxic synovitis.  Written by Natalie Pena-Brockett, MSIV, California Health Sciences University. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Having a limping kid can be terrifying. Many questions may cross your mind: Is this a permanent damage? What is going on here? Where is the pain located? Do I need to send this child to the hospital? Today, hopefully, we can help you ease some of your fears. Case: This is a 14-year-old boy with no past medical history, no trauma, presents to the family medicine clinic with a complaint of left-sided hip pain. Mom notes that her son has been limping for the last week and complaining of pain in his left hip and knee when he walks. He has never experienced this pain before this week. He does not take any medications. Physical exam: He is afebrile and all of his vitals are within normal limits. On exam, you note that his BMI is at the 90th percentile (overweight), and has an antalgic gait where he is favoring the right side and has tenderness on his left groin. His left foot is turned outward while standing up straight. His left knee has negative findings on specialized tests, but he has restricted movement of the left hip. Discussion: This is a common topic that you will see on board exams or limping into your office. Although pediatric hip pain may seem like a benign musculoskeletal concern, taking the time to take a complete history and perform a thorough physical exam is critical to assess the severity of the patient’s concern.Physical Exam for Pediatric Hip Pain.Observation: Every physical exam begins the moment you first see the patient. This allows you to gauge the patient’s comfort level, the natural stature, length, and positioning of the patient’s extremities, skin changes, gait, and ability to bear weight. Palpation: In medicine, our hands are one of our greatest tools for evaluating patients, especially those with musculoskeletal concerns. This is the time to palpate the area for any tenderness or gross deformities of the pelvis, hip, knee, or leg. Special Tests: In the world of MSK, we have all sorts of tests to evaluate the range of movement of our joints and tendons. When specifically evaluating the hip, the most common are the FABER(flexion, abduction, external rotation),test to assess the sacroiliac joint, Ober’s Test to assess the iliotibial band, and Straight Leg Raise to assess for lumbar radiculopathy.Legg-Calve Perthes Disease-Legg-Calve Perthes disease is an idiopathic avascular necrosis of the femoral head. -It is most commonly observed in patients between the ages of 2-12 years and in a higher ratio of males to females 1. -It often manifests as an atraumatic limp with limited movement in abduction and internal rotation. -X-ray imaging may demonstrate a widening of the joint space and sclerosis of the femur, and MRI will confirm osteonecrosis of the femoral head. -Early diagnosis is key to minimizing the risk of developing osteoarthritis of the hip. -The goal of treatment is to maintain the shape of the femoral head and the range of motion of the hip. -The first-line treatment includes managing pain with NSAIDs, limiting weight-bearing activity, and physical therapy for range of motion.-If the disease progresses, bracing and casting can be used to retain the femoral head within the acetabulum to keep the shape and integrity of the femoral head. In more serious cases, a surgical osteotomy may be done to cut and realign the bones. Developmental Dysplasia of the Hip (DDH)-Developmental Dysplasia of the Hip (DDH) is a pediatric condition that results in unilateral or bilateral instability of the hip due to the abnormal development of the acetabulum or femur. -This is most commonly seen in newborns, especially those which develop in a breech position. -These patients often present with a shortened leg or asymmetric gluteal creases and a Trendelenburg gait when walking. -The Trendelenburg gait is an abnormal gait caused by weak hip abductor muscles. The person's trunk shifts over the affected hip during the stance phase of walking and away from it during the swing phase, making it look like the person is missing steps or limping. -On physical exam, hip joint laxity can be evaluated with the Ortolani and Barlow maneuvers to apply pressure to the proximal femur to assess dislocatability of the hip joints. These maneuvers would both be considered positive if a “clunk” is felt over the hip as this means that the hip is dislocated with pressure. Due to the patient's age usually being under 6 months old, ultrasound is the most common imaging modality to confirm the diagnosis, otherwise, an X-ray can be used. -The treatment in patients under 18 months old, a Pavlik Harness is often used to treat patients to maintain the placement of the hip within the acetabulum. -Patients between the ages of 18 months and 9 years old, are most often treated with open or closed reduction of the hip. -There is generally less success in reduction treatment of children older than 9 years old as they have likely developed femoral head deformities and are at greater risk of osteonecrosis. -Children with DDH should continue to be monitored with regular imaging to evaluate for complications. These patients should also be made aware that they are also at increased risk of requiring a hip replacement, especially if their treatment included a reduction. 2Slipped Capital Femoral Epiphysis (SCFE)-Slipped Capital Femoral Epiphysis (SCFE) is one of the most common pediatric hip pathologies in which the capital femoral epiphysis is anterolaterally displaced from the femoral neck. -Although slightly more common in males than females between the ages of 10 to 16, the greatest risk factor for an SCFE is childhood obesity 3. -Common symptoms include an insidious onset of unilateral hip pain and a change in gait due to the displacement of the hip from the acetabulum. In some instances of chronic SCFE, some patients will experience ipsilateral knee pain due to compensation. -A SCFE can be evaluated with an AP radiograph which will demonstrate a widened physis in the early stages or the classic “slipped ice cream cone sign” which is the posterior displacement of the femoral epiphysis. -Management of a SCFE includes limiting weight-bearing activities as well as screw fixation by an orthopedic surgeon to stabilize the hip.Patients should consider pinning the contralateral hip due to increased risk of developing a future SCFE. Early diagnosis is critical as untreated SCFE can lead to osteonecrosis.Osgood-Schlatter-Osgood-Schlatter is a repetitive-use pediatric condition as a result of traction to the growth plate of the tibial tubercle. -This pathology is most common in male children between the ages of 9 to 14 years old 4. -Active athletes or children with rapid growth spurts are at greater risk of developing Osgood-Schlatter than non-active children.-These children often present with an achy knee pain that can lead to a unilateral limping gait.  On physical exam, these patients often have a bony prominence over the tubercle that is tender to palpation with greater tenderness over the patellar tendon. -The knee will have full range of motion and stability, but will likely have a warmth and erythema over the knee.  Imaging of the knees can have nonspecific findings and diagnosis is made clinically. -For management, it is recommended that children continue their regular activities and rest with NSAIDs for pain management as needed 5. Physical therapy can be prescribed to prevent deconditioning as this can result in recurrence or additional injuries.Arreaza: It seems like the pain is more localized to the knee, but it can be referred to the hip. If you have tenderness on the tibial tubercle, you got the diagnosis. Juvenile Idiopathic Arthritis (JIA)-Juvenile Idiopathic Arthritis (JIA) is a systemic rheumatologic condition in children that often presents as a polyarticular pain. The onset of disease is often bimodal with peaks between 2 to 5 years old and 10 to 14 years old. 6-Patients will often complain of minor symmetric joint pain and stiffness until an infection causes an inflammatory reaction that exacerbates the joint pain or can increase joint involvement. Small joints are the most likely to be involved, but hips and knees can also be affected. -Lab evaluation will demonstrate inflammation with an elevated ESR, low hemoglobin, and a positive ANA. -Disease management starts with NSAIDS for pain control and can escalate to immunosuppressive measures for moderate disease7.Toxic Synovitis-Toxic synovitis, also known as transient synovitis, is the leading cause of acute hip pain and limping in children aged 2–12, more commonly affecting boys. -This self-limited inflammatory condition, often confused by its name as "toxic," has no relation to a toxic state. It typically arises after an upper respiratory or other viral infection (e.g., rubella or coxsackie virus).-Children with toxic synovitis may show mild to moderate hip pain, limp, and keep their hip in abduction and external rotation. Movement is usually possible within a limited range, and weight-bearing is often maintained.-Evaluation: A thorough history and physical exam are key, as laboratory tests like CBC, ESR, and CRP are often normal, mainly used to rule out other conditions like septic arthritis. X-rays typically show no abnormalities, although small changes may appear. Ultrasound can help detect joint effusion and rule out septic arthritis if no effusion is present.Arreaza: DDX: DDH, SCFE, Osgood Schlatter, and toxic synovitis.Osteopathic Manipulative Treatment in Pediatric Hip PathologiesSacroiliac Articulatory Technique- this is a technique in which you move the joint into an out of its barrier to reduce restriction and improve movementCounterstrain of Tender points (psoas, piriformis, hip adductors)- in this technique we shorten the muscle to decrease tension.  This allows the muscle to increase blood lymphatic flow to reduce nociceptive and proprioceptive activity of the muscleBalanced Ligamentous Tension of the Innominate- with this technique, we manipulate the joint in a way that moves the ligaments into neutral position so that there is balance in all planes of motion.  The goal is to again release tension within the muscles and the jointClinical Decision Making Now that we have covered the most common differential diagnoses for pediatric hip pain, let’s revisit our patient presentation and identify the key characteristics to determine which diagnosis he most likely has.The patient is 14 years old.  This makes DDH and Legg-Calve Perthe less likely, and SCFE more likely.He has been complaining of symptoms for 1 week, which indicates that is not likely a chronic condition. This makes DDH and Osgood-Schlatter less likely.The patient has never experienced joint pain like this before.  This makes JIA, DDH, and Osgood-Schlatter less likely.The patient is overweight. This makes SCFE more likely.The unilateral hip tenderness and no knee pain.      This makes Osgood-Schlatter and JIA less likely.The patient has antalgic gait and limited internal rotation of the foot. This makes Legg-Calve Perthes and SCFE more likely. Now when we take the epidemiological factors, the history of the present illness, and the physical exam findings into account, this patient’s presentation best aligns with a SCFE. We would order a bilateral AP and Frog-leg views of the hips. If either imaging shows a widened physis or the classic “ice cream cone sign”, this is when we would start the referral process for an orthopedic surgery consultation for internal fixation. As family medicine physicians, we would give instructions for strict non-weight bearing activities and analgesics or anti-inflammatories for pain management.Keep in mind some of the DDX: Calve Legg-Perthes disease, Developmental Dysplasia of the Hip (DDH), Juvenile Idiopathic Arthritis (JIA), Osgood Schlatter, toxic synovitis, and Slipped Capital Femoral Epiphysis (SCFE). Hopefully, the next time you have a pediatric patient present with a complaint of hip pain, you’ll feel more comfortable evaluating and working up the case._________________________This week we thank Hector Arreaza and Natalie Pena-Brockett. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Osteonecrosis of the femoral head / Legg-Calvé-Perthes disease | Time of Care. Accessed October 27, 2024. https://www.timeofcare.com/osteonecrosis-of-the-femoral-head-legg-calve-perthes-disease/Scott EJ, Dolan LA, Weinstein SL. Closed Vs. Open Reduction/Salter Innominate Osteotomy for Developmental Hip Dislocation After Age 18 Months: Comparative Survival at 45-Year Follow-up. J Bone Joint Surg Am. 2020;102(15):1351-1357. doi:10.2106/JBJS.19.01278. https://europepmc.org/article/med/32769602Perry DC, Metcalfe D, Costa ML, Van Staa T. A nationwide cohort study of slipped capital femoral epiphysis. Arch Dis Child. 2017;102(12):1132-1136. doi:10.1136/archdischild-2016-312328. https://pubmed.ncbi.nlm.nih.gov/28663349/Haines M, Pirlo L, Bowles K-A, Williams CM. Describing Frequencies of Lower-Limb Apophyseal Injuries in Children and Adolescents: A Systematic Review. Clin J Sport Med. 2022;32(4):433-439. doi:10.1097/JSM.0000000000000925. https://pubmed.ncbi.nlm.nih.gov/34009802/Wall EJ. Osgood-Schlatter disease: practical treatment for a self-limiting condition. Phys Sportsmed. 1998;26(3):29-34. doi:10.3810/psm.1998.03.802. https://pubmed.ncbi.nlm.nih.gov/20086789/Oberle EJ, Harris JG, Verbsky JW. Polyarticular juvenile idiopathic arthritis - epidemiology and management approaches. Clin Epidemiol. 2014;6:379-393. doi:10.2147/CLEP.S53168. https://pubmed.ncbi.nlm.nih.gov/25368531/Beukelman T, Patkar NM, Saag KG, et al. 2011 American College of Rheumatology recommendations for the treatment of juvenile idiopathic arthritis: initiation and safety monitoring of therapeutic agents for the treatment of arthritis and systemic features. Arthritis Care Res (Hoboken). 2011;63(4):465-482. doi:10.1002/acr.20460. https://pubmed.ncbi.nlm.nih.gov/21452260/Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 179: Impact of intermittent fasting Impact on T2DMFuture Dr. Carlisle explains the physiology of fasting and how it can help revert type 2 diabetes. Dr. Arreaza adds details on how to do intermittent fasting. Written by Cameron Carlisle, MSIV, Ross University School of Medicine. Comments and edits by Hector Arreaza, MD, FAAFP.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is type 2 Diabetes Mellitus (T2DM)?-Type 2 Diabetes Mellitus (T2DM) is a metabolic disorder characterized by insulin resistance and impaired glucose regulation. -This impaired regulation can lead to hyperglycemia, contributing to complications in a myriad of organs: heart, kidneys, eyes, nerves, etc. (target organs). According to the CDC, more than 38 million Americans have T2DM (about 1/10 people). -Multiple mechanisms are believed to contribute to insulin resistance in obese patients with T2DM, such as increased lipid deposition throughout the body and systemic inflammation.What is Intermittent Fasting (IF)? Intermittent fasting (IF) has recently gained popularity as a dietary approach for health benefits, but it has been around for thousands of years. IF is an eating pattern that alternates between eating and fasting (no calories consumed) over a specific period of time. When you are fasting, you are allowed and encouraged to keep drinking water and non-caloric drinks, like coffee, tea, and even homemade bone broth.-According to the International Food Information Council Foundation (IFIC), 10% of Americans engage in IF daily. -According to Mark Mattson, a neuroscientist and IF expert for over 25 years, a mechanism called “metabolic switching” is seen with IF. This is when your body runs out of glucose and starts burning fat (i.e., fatty oxidation). These metabolic changes can help protect your organs and reduce the risk of chronic conditions, like T2DM. Common IF methods: Time-restricted eating: Most common method, involves eating within a specific time frame (e.g., the 16:8, 18:6, 12:12 method is also common.  [16:8 means you have 16 hours of fasting and 8 hours of eating.]Alternate-day fasting: Alternating between fasting days and normal eating days.  [Find more info in The Complete Guide to Fasting, by Jason Fung, who is a nephrologist, he explains that alternate-day is basically eating every other day, which would give 36 hours of fasting, but if you are a beginner you can try a 24 hours fasting, in short, not eating breakfast any day of the week and having lunch 4 days a week, and dinner every night.]5:2 diet (aka periodic fasting): Maintaining a normal diet for 5 days, with 2 days (usually non-consecutive) of caloric restriction (25% of normal caloric intake; e.g., 500 calorie meal). IF is strongly believed to improve metabolic health in individuals with T2DM by reducing insulin resistance via increasing insulin sensitivity, promoting weight loss (patients with obesity and DM… AKA patients with diabesity), and enhancing lipolysis via fat oxidation.While fasting, the body goes through several phases that affect how energy is metabolized. Between 0 and 4 hours after eating, the body enters a feeding state, using glucose as its main energy source. After fasting for 12-16 hours, the body enters ketosis and starts to use fat for energy. Within 24-36 hours, autophagy begins, a process that recycles damaged cells and allows for cellular repair. This process can have great benefits for people with T2DM, such as improved insulin sensitivity and glucose regulation. Pathophysiology of Implementing IF in T2DM. -IF is thought to increase insulin sensitivity by decreasing fatty tissue in the body (i.e., visceral adipose tissue), which is correlated to insulin resistance. Insulin resistance is defined as higher than normal circulating insulin levels needed for a glucose lower response, which is thought to be the culprit for the generation of T2DM. It means you need high levels of insulin to keep glucose normal. -Obesity is an important risk factor for T2DM. Visceral adipose tissue functions as an organ via the secretion of adipokines (cytokines or cellular messengers produced by adipose tissue): leptin and adiponectin. Leptin: proinflammatory, leading to chronic inflammation. Patients with higher BMI levels and increased insulin resistance were found to have increased leptin levels.[Leptin is a good hormone at normal levels, but there is leptin resistance] Adiponectin: anti-inflammatory and antidiabetic effects. Higher adiponectin levels result in decreased hepatic gluconeogenesis, enhanced glucose absorption, and enhanced skeletal muscle and hepatic fatty acid oxidation. Levels drop as visceral fat increases. -Dr. López-Jaramillo, a Colombian endocrinologist and researcher, and colleagues published a review in 2014 examining the imbalance in the levels of leptin and adiponectin in individuals with metabolic syndrome. This imbalance (increase in leptin and decrease in adiponectin) is linked to obesity and insulin resistance, which has been shown to increase the risk of T2DM. It has been shown that IF has resulted in the reduction of leptin levels and increased levels of adiponectin, which leads to decreased insulin resistance and increased insulin sensitivity. -IF allows pancreatic beta-cells to rest by not having to secrete insulin constantly. This allows the beta-cells of the pancreas to improve in function over time. In addition, IF has been shown to lead to noticeable weight loss and loss in body fat, both of which play an important contribution in managing T2DM. Research demonstrates that this weight loss increases insulin sensitivity and decreases the need for insulin therapy, making IF a powerful approach for improving metabolic health. AMP-Activated Protein Kinase (AMPK) and Its Role in IF and T2DM Recent research has highlighted an important enzyme seen in IF, AMP-activated protein kinase (AMPK), which plays a vital role as an important energy sensor in cells. It is activated when cellular energy levels are low, such as during IF. A 2020 research study in Nature Reviews Endocrinology explains that activation of AMPK aids in suppressing gluconeogenesis and stimulates fatty acid oxidation, leading to optimal energy balance and reduction of visceral adipose tissue accumulation, a major contributor to insulin resistance and T2DM progression. AMPK is upregulated during fasting, which enhances glucose metabolism and reduces insulin resistance. This is imperative in managing T2DM, as it counters the effects of insulin resistance associated with T2DM.Exercise, which also promotes AMPK activation, complements IF and can promote a synergistic effect in improving insulin sensitivity and promoting fat burning, New Research Findings on IF and T2DM -The EARLY (Exploration of Treatment of Newly Diagnosed Overweight/Obese Type 2 Diabetes Mellitus) study is a randomized clinical trial published in JAMA Network Open (2024). Findings In this randomized clinical trial study found that a time-restricted eating window significantly improved fasting glucose levels and HbA1c levels in individuals with T2DM. The study examined the effect of a 16-week 5:2 meal replacement (5:2 MR) fasting plan that consisted of five days of normal eating and 2 days, nonconsecutive of restricted diet (500-600 calories). This group was examined alongside a group of patients who took metformin 0.5 g BID and empagliflozin 10 mg QD. The study wanted to investigate the changes in HbA1c in Chinese adults with early T2DM.-The study was a randomized clinical trial of 405 adults, and a study showed that the 5:2 MR approach led to better glycemic control at 16 weeks compared to the counter treatments with metformin and empagliflozin. The 5:2 MR group had the greatest reduction in HbA1c (-1.9%), followed by metformin (-1.6%), and empagliflozin (-1.5%). The 5:2 MR plan also revealed the greatest weight loss (-9.7 kg), followed by empagliflozin (-5.8 kg), and metformin (-5.5 kg). -This research suggests IF, such as 5:2 MR, can be a powerful tool in the management of T2DM and improving metabolic health. This study can potentially open doors for healthcare providers to provide the 5:2 MR approach for individuals as an effective initial lifestyle intervention. However, follow-up studies are needed to assess the effectiveness and durability of the 5:2 MR.Safety and Risks of IF in T2DM. -IF when combined with glucose-lowering medications (e.g., insulin, sulfonylureas, GLP-1 agonists) can increase the risk of hypoglycemia. Also, prolonged fasting can lead to nutrient deficiencies if not planned carefully. Patients should be counseled on maintaining a balanced, nutritious diet during non-fasting days. -IF is not suitable for everyone. Children under the age of 18 should not try IF due to needing proper calories for adequate development and proper growth. Also, it is recommended that pregnant or breastfeeding women do not undergo IF. It is advised that people with eating disorders should not try IF. -Individuals with certain medical conditions, such as kidney stones or gastroesophageal disease should speak with their doctor before trying IF. Also, patients on insulin or other glucose-lowering medications should adjust their dose and talk with their healthcare providers to prevent hypoglycemia during fasting. It is recommended that each person speak with their doctor to discuss the safety and risks of IF and see if it would benefit the individual before starting IF. -Many studies have explored the benefits of IF at the micro level revealing its cellular benefits and on a macro level of the body as a whole. However, more research is needed to confirm the long-term effects of IF on glycemic control and its sustainability as a therapeutic approach for T2DM. Conclusion:-IF shows potential for improving glycemic control, promoting weight loss, and enhancing metabolic health in individuals with T2DM. Despite its benefits, IF may present with risks, such as hypoglycemia, nutrition deficiencies, or dehydration in certain patients. Therefore, it may not be suitable for all individuals. It’s important to monitor patients who engage in IF, especially for patients with T2DM. Patients should follow up with their doctor for individualized IF plans in patients with T2DM. ______________This week we thank Hector Arreaza and Cameron Carlisle. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Albosta, Michael, and Jesse Bakke. “Intermittent Fasting: Is There a Role in the Treatment of Diabetes? A Review of the Literature and Guide for Primary Care Physicians - Clinical Diabetes and Endocrinology.” BioMed Central, BioMed Central, 3 Feb. 2021, doi.org/10.1186/s40842-020-00116-1.Blumberg, Jack, et al. “Intermittent Fasting: Consider the Risks of Disordered Eating for Your Patient - Clinical Diabetes and Endocrinology.” BioMed Central, BioMed Central, 21 Oct. 2023, https://clindiabetesendo.biomedcentral.com/articles/10.1186/s40842-023-00152-7.De Cabo, Rafael, and Mark P. Mattson. “Effects of intermittent fasting on health, aging, and disease.” New England Journal of Medicine, vol. 381, no. 26, 26 Dec. 2019, pp. 2541–2551, https://doi.org/10.1056/nejmra1905136.Guo, Lixin, et al. “A 5:2 intermittent fasting meal replacement diet and glycemic control for adults with diabetes.” JAMA Network Open, vol. 7, no. 6, 21 June 2024, https://doi.org/10.1001/jamanetworkopen.2024.16786.Herz, Daniel, et al. “Efficacy of Fasting in Type 1 and Type 2 Diabetes Mellitus: A Narrative Review.” Nutrients, U.S. National Library of Medicine, 10 Aug. 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10459496/. Herzig, S., & Shaw, R. J. (2018). AMPK: Guardian of metabolism and mitochondrial homeostasis. Nature Reviews Molecular Cell Biology, 19(2), 121-135.Longo, V. D., & Mattson, M. P. (2014). Fasting: Molecular mechanisms and clinical applications. Cell Metabolism, 19(2), 181-192. https://doi.org/10.1016/j.cmet.2013.12.008López-Jaramillo P, Gómez-Arbeláez D, López-López J, et al. The role of leptin/adiponectin ratio in metabolic syndrome and diabetes. Hormone Molecular Biology and Clinical Investigation. 2014;18(1):37–45.Mattson, Mark P., et al. “Impact of intermittent fasting on health and disease processes.” Ageing Research Reviews, vol. 39, Oct. 2017, pp. 46–58, https://doi.org/10.1016/j.arr.2016.10.005. Patikorn, Chanthawat, et al. “Intermittent fasting and obesity-related health outcomes.” JAMA Network Open, vol. 4, no. 12, 17 Dec. 2021, https://doi.org/10.1001/jamanetworkopen.2021.39558.Sharma, Suresh K, et al. “Effect of Intermittent Fasting on Glycaemic Control in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.” TouchREVIEWS in Endocrinology, U.S. National Library of Medicine, May 2023, www.ncbi.nlm.nih.gov/pmc/articles/PMC10258621/#:~:text=In%20IF%2C%20eating%20habits%20are,the%20risk%20of%20developing%20T2DM.Xiaoyu, Wen, et al. “The effects of different intermittent fasting regimens in people with type 2 diabetes: A network meta-analysis.” Frontiers in Nutrition, vol. 11, 25 Jan. 2024, https://doi.org/10.3389/fnut.2024.1325894. Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 178: Social Media in MedicineDr. De Luna and Dr. Song explain the role of social media in medical education and how online journal clubs have become more useful in recent years.  Dr. Arreaza offers insights into our role as educators and sources of truth.Written by Patrick De Luna, MD. Comments by David Zheng Song, MD, and Hector Arreaza, MDYou are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro to episode (voiceover): Get ready to listen to a great conversation between three doctors diving into the impact of social media on medicine. It’s no secret that social media shapes our lives—not just as professionals, but also as humans and members of our society. Every second, new information floods our feeds, and with the rise of artificial intelligence, it’s becoming harder to separate fact from fiction. As doctors, we have a crucial role in clearing up confusion and supporting evidence-based practices. You’ll hear insightful tips from Dr. De Luna, Dr. Song, and Dr. Arreaza—but remember, you also have a role in spreading the truth, you must be a reliable source of online truth and correct misinformation quickly. Also, use reliable sources, recommend fact-check websites, including Snopes, and FactCheck.org, and avoid “back-and-forth” arguing about fake news online, because as you keep arguing, fake news will continue to spread.Social Media in Medicine.Patrick: Social media has helped both physicians and patients obtain and expand their knowledge of medicine. This role in medical knowledge expansion has been more prevalent since the COVID-19 pandemic, especially in the form of podcasts (like this one), medical content creators, and personalities.  This growing medium has helped physicians to deliver medical knowledge in an efficient, but layman, format which can become a great outreach and educational tool. Arreaza: This podcast was created 3 days before the lockdown. It has been an educational tool for those who record and hopefully for those who listen to us.Patrick: In today’s episode, we will explore a little about how this more accessible approach to medical learning has shaped our medical education landscape. We’ll explore a recent study that shows the breakdown of how social media is used among medical professionals and the concerns that physicians have about medical education through social media. We will discuss how platforms such as X/Twitter have “Journal Club” threads and their implications. Furthermore, will discuss how online personalities have been able to bring medical education discussion to the broader population, and what we can learn from their work. David: Who is your favorite medical educator?Patrick: Dr. Mike (YouTube FM), Dr. Glaucomflecken (ophthalmologist comedian), and HealthyGamerGG (gamer), and yours?David: Curbsiders (THE internal medicine podcast)Arreaza: I like Dr. Glaucomflecken as well. He is a comedian but he is becoming a little more political. The AFP podcast is my favorite.David: We will explore and discuss how we could make quality and accurate medical education content and, hopefully, mitigate concerns about creating future educational content for physicians and patients alike. Analysis of Healthcare Professional Social Media UsePatrick: Social media has traditionally been used to share about your social life (posting pictures of your cat and family vacation), stay up to date on news and what is happening among your peers, as well as (for some select folks) a platform for content creation and a means of a career. Healthcare professionals also participate in social media in the same manner. David: Some social media users are called “influencers”. Arreaza: The term “influencer” is becoming a somewhat negative term online because many “influencers” are giving a bad reputation to that term, to the point that many prefer to be called “content creator.”Patrick: In a recent study published in Taylor and Francis’ Medical Education Online, 72.1% of the participants reported use of social media to some degree. Out of the 72%, 11.5% of the surveyed report using social media sites exclusively for professional purposes, 22.8% for strictly personal use, and 65.7% for both. David: The most used social media platforms among healthcare workers were Facebook at 70%, YouTube 58%, LinkedIn 52%, Instagram 42%, Twitter (now called X) 27%, TikTok 10%, and Reddit at 5% among those surveyed. Those are 6 different media, which ones do you currently use, Patrick?Patrick: [Add response]. 20.4% of the surveyed indicated they use clinically focused social media platforms as well. This same survey found that respondents specializing in addiction medicine, family medicine, pediatrics, and psychiatry were more likely to use social media for continued professional development as compared to other specialties. David: Social media among the participants was highly used for staying informed with medical news and actively participating in medical discussions online, especially about medical management and treatments. Of note, the data is based on a population that skews more toward physicians and medical professionals who have practiced for more than 15 years. Arreaza: Doximity is one of those platforms that I have used in the past, and it contains interesting articles but they have to be read “with a grain of salt,” because they are editorials.The “New Journal Club” OnlinePatrick: Multiple residency programs report using social media as a form of engagement about published journal articles and updates to medical practice. Medical education may benefit from the implementation of social media and similar platforms as a medium for professional development, according to an analysis performed by Medical Education Online. The use of social media among many physicians has changed from content consumption (passive) to active participation in furthering medical education. David: This is reflected heavily in how platforms such as X (formerly known as Twitter), have become a forum towards a new form of “Journal Club”.Tweet Threads can now be utilized for further publication discussion in an open online space.  Good examples of this can be found among Twitter feeds from publication sites like the New England Journal of Medicine or #IDJClub (Before their move to Meta’s Threads in November 2023). The Infectious Disease Journal Club, using the handle @IDJClub, published a study in May 2022 highlighting the impact of 20 months of journal club hosting through Twitter.Patrick: The authors of the study state that it may be harder for physicians outside of academic circles to have opportunities for well-scaffolded discussions and continued maintenance of critical appraisal skills. Due to an explosion of questionable medical literature during to COVID-19 pandemic (AKA fake news), they report a higher need for avenues to keep the practice of critical appraisal, thus we need to expand journal club access outside of academic sites.Arreaza: From May 19, 2019 – August 7, 2021, the @IDJClub account was followed by almost 9,500 followers from 114 countries and hosted 31 journal club posts and discussions. During the study, they found data that shows a decrease in participation in journal clubs use in residencies, as well as a lack of expert hosts to lead those discussions. Patrick: In addition to the increased accessibility, the survey makes a case that online interdisciplinary journal clubs can be an effective tool to update medical professionals and for practicing critical appraisal of the research studies. 75% of respondents believed that they learned more from these #IDJClub discussions than in their traditional journal club forums (if such forums were available to their respective programs). A case is made where it could be reflective of easier access, the make-up of how the publication is presented, and how the overall journal club is run. Concerns and Challenges to AvoidDavid: As well-intended and useful as these platforms for medical education can be, some authors from AAFP recommend that we be mindful of problems that can occur from misapplied use. Patrick: One problem that has been brought to the AAFPs' attention is potential society and licensing board actions. Medical boards, such as our own California Medical Board, can sanction physicians, uphold practice restrictions, or even take away physician licenses due to unprofessional behavior in social media content creation. This is especially worrisome if posting scientifically misleading or untrue claims.David: One example was an incident here in Bakersfield where 2 physicians used YouTube to post the results of COVID-19 tests at their urgent care during the peak of the pandemic. They misled the public in stating the disease did not have serious ramifications as the CDC stated. Due to the large number of viewers, the physicians were censured by medical societies due to their distribution of biased and unfounded information to the public. Patrick: AAFP authors suggest that for medical statements and discussions posted on social media for general patient education, it is recommended to add hyperlinks or direct sources with any online interaction in-so-that it better qualifies accuracy. If it’s unverifiable, it would be best to add written caveats about the information’s non-verifiability or that it is in the process of continued research. Patrick: At this time, there is some effort made by social media platforms to help indicate that the post is made by a reputable source. For example, when a licensed medical professional posts on YouTube, there are information panels that appear that will give context to the health content that is viewed. At the time of this episode, YouTube also currently allows channels to apply to be indicated as a licensed medical professional in the channel's posts. The applicants are examined by three different medical societies: the Council of Medical Specialty Societies (CMSS), the National Academy of Medicine (NAM), and the World Health Organization (WHO) to standardize how health education should be shared online. David: An example being Dr. Lin of Common Sense Family Doctor, an online medical blog for patients and physician education. In his statement to AAFP, he states that he wanted to post educational content twice a week, however, it required 3 to 4 hours a week to create. This can be time-consuming and distracting from other responsibilities.Arreaza: Social media can change mind. What other concerns do you think should be considered when physicians try to educate patients in an online environment?Social Media Platforms to Teach Medicine to the Greater Public Patrick: In general, social media platforms can be used to educate the public. One AAFP panel of authors wrote that some key points are important to consider when creating online content that is meant for public use.We must define our goals toward the subset population we are directing the education towards. Is it providing general health education? Is it promoting a practice? Is this used to advocate for a cause?We must consider who our audience is. For example, if our goal is to create a professional message to incite political or societal change towards public health policy, it would be best to utilize platforms that involve policymakers, political leaders, and/or patients that can inform them of what we want to achieve. Focus on general topics. These can include topics such as viral medical discussion trends on platforms like TikTok (ex. Ozempic), fitness and wellness, nutrition, or topics that you yourself have interest or expertise in. This can lead to the production of original content such as informatic YouTube series’, podcasts such as this one, or discussion threads. AAFP recognizes that this can become a creative outlet for physicians and can reduce burnout.ConclusionPatrick: We can see the transformative impact of social media on medical education, and how it’s further evolved since the COVID-19 pandemic. We explored how platforms like Twitter have redefined traditional journal clubs, making scholarly discussions more accessible across global medical communities. Moreover, we examined the role of influential medical content creators in bridging the gap between healthcare professionals and the general public. Patrick: While social media presents unprecedented opportunities for disseminating medical knowledge, our discussion also highlighted the challenges, including the need for accuracy in content, navigating professional conduct, and addressing algorithmic biases that can influence online interactions.Patrick As we conclude, it's evident that social media has revolutionized medical education by fostering broader engagement and democratizing access to knowledge. However, both physicians and content creators must uphold ethical standards and ensure the accuracy of information shared online. By navigating these challenges thoughtfully, we can harness its full potential as a powerful tool for advancing medical education and improving health outcomes in our local communities. ____________________This week we thank Hector Arreaza, Patrick De Luna, and David Zeng Song. Audio editing by Adrianne Silva. Intro by Raj Ajudia, MSIII. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________Links:Topf, Joel M., Introduction: Social Media and Medical Education Come of Age, Seminars in Nephrology, Volume 40, Issue 3, 247 – 248. https://www.seminarsinnephrology.org/article/S0270-9295(20)30043-7/fulltextNguyen BM, Lu E, Bhuyan N, Lin K, Sevilla M. Social Media for Doctors: Taking Professional and Patient Engagement to the Next Level. Fam Pract Manag. 2020;27(1):19-14. https://www.aafp.org/pubs/fpm/issues/2020/0100/p19.htmlIserson KV, Derse AR, Delpier M. Navigating the Hazards of Social Media. Fam Pract Manag. 2022;29(3):15-20. https://www.aafp.org/pubs/fpm/issues/2022/0500/p15.htmlVan Ravenswaay L, Parnes A, Nisly SA. Clicks for credit: an analysis of healthcare professionals' social media use and potential for continuing professional development activities. Med Educ Online. 2024 Dec 31;29(1):2316489. doi: 10.1080/10872981.2024.2316489. Epub 2024 Feb 15. PMID: 38359156; PMCID: PMC10877644. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10877644/Doctor Mike, YouTube Channel, https://www.youtube.com/@DoctorMikeDr. Glaucomflecken, YouTube Channel, https://www.youtube.com/@DGlaucomfleckenHealthyGamerGG, YouTube Channel, https://www.youtube.com/@HealthyGamerGGGet info on health-related content, Google Support, https://support.google.com/youtube/answer/9795167Apply to be a source in YouTube health features, YouTube Help, https://support.google.com/youtube/answer/12796915Theme Song: Works All The Time by Dominik Schwarzer, License #5924333, PremiumBeat.com.  

Episode 177: Urinary Incontinence in Older AdultsFuture Dr. Nguyen explains the evaluation and treatment of older adults with urinary incontinence.  Dr. Arreaza adds insights into the conservative management of urinary incontinence.Written by Vy Nguyen, MSIV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific-Northwest. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition of urinary incontinence. The International Continence Society (ICS) defines it as any involuntary urine leakage. Epidemiology of urinary incontinence. Data analysis from the National Health and Nutrition Examination Survey (NHANES) from 2015 to 2018 shows that more than 60% of adult women which is equivalent to around 78,000,000 females living in the United States experience urinary incontinence with 32.4% reporting symptoms monthly. More data analysis shows the strongest association with urinary incontinence include age greater than 70, prior vaginal delivery, and BMI of 40 or greater. Despite urinary incontinence commonly affecting the senior population, this medical condition can also affect the quality of life of younger adult females and males. On top of that, urinary incontinence is often underestimated due to the low report level for various reasons and the obtained data might not accurately reflect the true prevalent rate. Types and etiology.Urinary incontinence is divided into 5 categories: stress, urge, mixed, overflow, and functional. Stress urinary incontinence has the highest prevalence of 37.5% followed by mixed urinary incontinence at 31.3%, urgency at 22%, and unspecified urinary incontinence at 9.2%. Due to time constraints, we will discuss the most prevalent type which is stress urinary incontinence.In females, stress urinary incontinence is often due to urethral sphincter hypermobility caused by weakened pelvic floor muscles. It can also be caused by dysfunction of the sphincter muscle that is exacerbated by increased intraabdominal pressure from coughing, sneezing, or physical exertion. This type of incontinence is commonly seen in pregnant women, those who experienced childbirth, and young women active in sports. In males, the most common etiology for stress urinary incontinence in males is prostate surgery such as radical prostatectomy which can damage the external urethral sphincter. Another cause is spinal cord injury or disease that can interfere with sphincter function. Evaluation. Urinary incontinence is first evaluated by a thorough history taking that includes inquiries about the type, severity, burden, and duration of incontinence. The initial evaluation includes a voiding diary that can provide clarity and help distinguish between the different types of incontinence or identify the dominating type in the case of mixed incontinence. Examples of voiding diary can be found on the websites of International Urogynecological Association (IUGA). Medical conditions such as COPD and asthma can induce cough; heart failure can cause volume overload; neurological disorders and musculoskeletal conditions can interfere with bladder emptying and urinary retention and thus should also be investigated. It is also helpful to ask about medication and substance use as the adverse effects can directly or indirectly contribute to urinary incontinence. For our female-identifying patients, a gynecological and obstetrical history such as birth history (vaginal versus c-section), current pregnancy as well as low estrogen (menopause) can contribute to reversible urinary incontinence. Management. There are various treatment modalities for stress urinary incontinence ranging from conservative to more invasive surgical management. Conservative treatment: -Initial treatment includes pelvic floor strengthening exercises and bladder training with scheduled void. -Pelvic floor muscle training (PFMT) is very effective, and it is proven to help achieve cure and improve the quality of life in women with ALL types of urinary incontinence. -For stress urinary incontinence, the median cure rate is around 58.8% for women after 12 months and 78.8% for men at 6 months of supervised pelvic floor muscle training (PFMT). -Certain behavioral modifications such as fluid intake management (-According to an AFP article, Cochrane for Clinicians, patients who have obesity may benefit from weight loss, improving the cure rate and improvement of symptoms in any type of urinary incontinence. SOR: B.-Conservative management should be implemented for 6 weeks before considering other options. -Supplemental modalities can also be introduced in addition to pelvic floor exercises; those include vaginal weighted cones, biofeedback alone or with electrical stimulation. -Vaginal cones and electric stimulation are more effective than control at achieving cure or improving symptoms in patients with stress urinary incontinence.-In the case that initial management does not offer relief, physicians can consider support devices such as pessaries. However, their use is associated with a high incidence of UTIs and doesn’t have long-term efficiency. Medications.-In terms of pharmacologic treatments, several medications are being evaluated such as duloxetine and alpha-adrenergic agonists, but the FDA has yet to approve any medications for stress urinary incontinence. Invasive treatment:-Lastly, patients without sufficient control of their incontinence via initial management or pessaries should be considered for surgical management. -Mid-urethral sling procedures have become the standard surgery for stress urinary incontinence due to their minimally invasive approach, rapid recovery, low-risk complications, and high cure rates and thus is the single most investigated procedure with the strongest evidence for its use. Around 53% after 3 years for males who received slings and 84.4% at 12 months for women who received surgical interventions. -Trans- or periurethral injections of bulking agents are also commonly used given the low invasive nature and rapid recovery. -Other procedures such as intravesical balloons, and electrical stimulation of pelvic floor can offer some benefits though data remains limited. Response rate often varies depending on the type of incontinence and treatment. Multiple modalities should be explored if symptoms persist. Conclusion:-Urinary incontinence affects various physical, mental, and social aspects of our patients’ lives and thus can interfere with work, travel, exercise, and sexual activities. While it is a common presentation in elderly adults, it is imperative to emphasize that it is not part of normal aging. One survey shows almost three out of four women with urinary incontinence hesitate to disclose their symptoms and only 60% of those who tried to address their symptoms receive treatments. -Our patients might also see us as their sons, daughters, or even grandchildren and are reluctant to share their symptoms due to embarrassment. As we observe and approach our patients with compassion, we can help these individuals understand that many of these symptoms have reversible causes and can be managed to allow for a better quality of life.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Patel, Ushma J, et al. Updated Prevalence of Urinary Incontinence in Women: 2015–2018 National Population-Based Survey Data. Female Pelvic Medicine & Reconstructive Surgery 28(4):p 181-187, April 2022.https://journals.lww.com/fpmrs/abstract/2022/04000/updated_prevalence_of_urinary_incontinence_in.1.aspxTran, Linh and Puckett, Yana. Urinary Incontinence. National Library of Medicine. Last updated Aug 8, 2023.https://www.ncbi.nlm.nih.gov/books/NBK559095/Clemens J, et al. Urinary incontinence in males, Up to Date, last updated: Mar 26, 2024. https://www.uptodate.com/contents/urinary-incontinence-in-males. Lukacz, Emily, et al. Female urinary incontinence: treatment and evaluation, Up to Date, last updated: Apr 2024. https://www.uptodate.com/contents/female-urinary-incontinence-treatment.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

Episode 176: Self-sampling for HPV screeningFuture Dr. Markarian explains the importance of HPV screening for the prevention of cervical cancer. Dr. Arreaza adds some insight about cervical cancer.Written by Chantal Markarian, MSIV, American University of the Caribbean. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Insights into Cervical Cancer.Chantal: Cervical cancer stands as the most prevalent form of cancer in women globally costing the lives of approximately 350,000 women annually. About 4,000 women die of cervical cancer a year in the US. Cervical cancer is initially asymptomatic, allowing it to advance to a more severe stage if not detected early. The positive news is that cervical cancer is highly preventable through screening for precancerous lesions or the presence of HPV —the primary culprit behind most cases.The role of HPV: Human Papilloma Virus, according to the World Health Organization, caused an estimated 620,000 cancer cases in women and 70,000 cancer cases in men.Cervical cancer is more prevalent in certain regions. In regions with established screening initiatives, the incidence rate and mortality rate of cancer are lower than in resource-limited areas. This highlights that resource-constrained countries continue to bear a burden of this disease. In nations like the United States, access to the HPV vaccine along with routine screenings, like Pap smears and HPV tests has significantly decreased the prevalence of cervical cancer.Screening recommendations from the US Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS).The U.S Preventive Services Task Force advises that women aged 21 to 29 undergo a Pap test every three years while those aged 30 to 65 should opt for co-testing (Pap and HPV tests) every five years. These examinations are usually conducted in outpatient facilities, where a medical professional collects a sample of cervical cells that are later examined under a microscope.A normal result states that the sample was adequate for evaluation, in other words, that endocervical/transformation zone components are present, and that the patient is “Negative for intraepithelial lesion or malignancy.” ACS recommends cervical cancer screening begin at age 25 for women and people with a cervix. Those aged 25 to 65 should have a primary HPV test every 5 years. (A primary HPV test means the HPV test is done without cytology; follow-up screening can be done with a Papanicolaou (Pap) test if needed.) If primary HPV testing is not available, screening may be done with either a co-test every 5 years, which combines an HPV test with a Papanicolaou (Pap) test, or a Pap test alone every 3 years. How is Cervical Cancer Classified?Two systems categorize lesions: the Cervical Intraepithelial Neoplasia (CIN) scale and the Bethesda system.The CIN scale categorizes lesions based on the degree of involvement of the cervical lining ranging from mild (CIN I) to moderate (CIN II) to severe dysplasia (CIN III).The Bethesda system emphasizes cytological findings organizing results into categories such as atypical squamous cells, low-grade lesions (LSIL), and high-grade lesions (HSIL).ASCUS (Atypical Squamous Cells of Undetermined Significance) is the most common abnormality seen in pap smears. It may or may not indicate a problem, you have to make a decision based on the patient. Cervical cancer is largely linked to high-risk HPV (hrHPV), mostly HPV 16 and 18, and scientists are investigating tests that identify hrHPV DNA or RNA. These tests may provide a more accurate evaluation of cancer risk compared to traditional cytology. Examples include DNA amplification tests like Cobas test and the Xpert HPV test.Obstacles to Screening.Despite the efficacy of cervical cancer screening, many women face many obstacles to testing. In regions with limited resources, fear, embarrassment, lack of awareness, and restricted healthcare access pose challenges to screening.In Nigeria, a study revealed that women often avoid Pap smears due to a lack of awareness. Similarly, healthcare providers in Ecuador highlighted issues like the absence of screening programs and inadequate health promotion efforts. Women in Peru face obstacles such as long waiting times preferences for female healthcare providers and limited access to health facilities. In 2022, 31% of minority women in the US did not undergo Pap smears in the past three years; many of these women were uninsured, unemployed, or low-income. These challenges contribute to higher rates of cervical cancer among women who do not follow recommended screening guidelines.We must mention the cultural obstacle as well. Some cultures do not allow any kind of pelvic exams before marriage. They put a major emphasis on being a “virgin,” and placing a speculum in the vagina may be considered culturally unacceptable. In those cases, the doctor has to use their best persuasion skills to accomplish the goals of care. For example, they may suggest having the mother in the room during the pap smear, using the smallest speculum possible, or other techniques.Self-sampling.In 2020, the World Health Organization (WHO) introduced a global initiative to combat cervical cancer worldwide. The initiative aims to:Vaccinate 90% of girls by age 15.Screen 70% of women by age 35.Treat 90% of women with lesions and invasive cancer by 2030.To achieve these goals, self-sampling for HPV testing has been introduced as a viable option for cervical cancer screening. Self-sampling for HPV testing is seen as an alternative for cervical cancer screening that addresses barriers associated with traditional methods. This approach enables women to take samples themselves using swabs or brushes removing the necessity for a pelvic examination. The option to mail in samples and receive results within two weeks enhances the convenience, privacy, and accessibility of the process giving individuals control over their health.While self-sampling for hrHPV detection is not currently standard practice in the United States, it has been successfully implemented in countries across Europe, Africa, and South America. Pilot studies are ongoing in nations like Canada and New Zealand to assess its effectiveness offering promise for its impact.In May 2024, the Food and Drug Administration (FDA) approved primary HPV self-collection for cervical cancer screening in a health-care setting. That means, the patient still has to go to a clinic to self-collect her sample. How Effective is HPV Self-Sampling?Research supports the accuracy of HPV self-sampling. A study conducted by Polman et al., which involved a randomized controlled trial, demonstrated that HPV tests on self-collected samples were just as precise as those done on samples collected by clinicians in detecting high-grade lesions (CIN II and CIN III). Similarly, a meta-analysis conducted by Arbyn et al. showed no difference in sensitivity or specificity between self-sampled and clinician-sampled tests for detecting CIN grade II or higher.These results indicate that self-sampling could be an adequate screening method for cervical cancer. This reassurance may motivate women to partake in screenings knowing they have a convenient and effective option. Ok, let’s say a patient has collected her sample or the sample was collected by a clinician, what is next?Management of Cervical Cancer Screening Results.The process of managing cervical cancer screening results involves evaluating a patient’s immediate and five-year risk of developing cervical abnormalities (CIN 3+) following guidelines from the American Society for Colposcopy and Cervical Pathology (ASCCP).The ASCCP app is the best investment you can make in primary care. It is only $9.99, but it can save you a lot of time in clinic. Estimating risk is a process that considers factors such as current HPV test results, past screening outcomes, the patients' age, and whether they’ve had a hysterectomy or not. When Risk is Elevated, Prompt Action.If a patient’s immediate risk of developing CIN 3 exceeds 4%, expedited treatment is typically recommended. This treatment may entail one of several procedures aimed at removing abnormal cervical tissue.Loop Electrosurgical Excision Procedure (LEEP): A common method that removes tissue using an electric wire loop. Cold Knife Conization: In this procedure, a scalpel removes a cone-shaped section of the cervix.Laser Cone Biopsy: This technique involves removing a cone-shaped section of tissue using a laser.Alternatively, healthcare providers may opt for treatment methods such, as cryotherapy, thermos-ablation, and laser ablation to eliminate abnormal tissue.And those procedures are typically out of the scope of family medicine, but many family doctors may perform them with the proper training and experience.When the risk is deemed low, Surveillance.Patients with a risk of CIN 3 below 4% are typically advised to undergo surveillance with HPV testing every 1-5 years. If HPV testing is not available cytology alone (Pap test) is considered acceptable.Special considerations for women.For women under 25, a cautious approach is taken. If a low-grade lesion (LSIL) is identified through cytology, it is recommended to repeat the test annually for two years. If two consecutive tests show normal results the patient can resume screening intervals based on age. However, if a high-grade lesion (HSIL) is detected, a colposcopy and biopsy are recommended. It should be noted that expedited treatment is generally not advised for this age group since many high-grade lesions may resolve spontaneously.For women over 25, the presence of low-grade lesions or persistent high-risk HPV often leads to recommendations for colposcopy and cervical biopsy.When a cervical biopsy shows adenocarcinoma in situ it is suggested to perform an excisional procedure to rule out invasive cancer. The next steps depend on the margins of the excised tissue; If the margins show positive results (indicating abnormal tissue remains) further excision is necessary to ensure clear margins. This may be followed by a hysterectomy due to the risk of residual disease. For individuals who have been treated for high-grade lesions there is still a risk of developing cervical cancer. Therefore, long-term surveillance is essential. Women over 25 should undergo HPV testing six months after treatment, then annually until three consecutive negative tests are obtained. Subsequently testing every three years is advised for 25 years. As for women under 25, cervical cytology should be done six months post-treatment. Then at six-month intervals until three consecutive negative results are achieved. Once they reach 25 years old, they should switch to HPV testing.As summary, HPV is the most common cause of cervical cancer, and screening must be implemented no matter what your zip code is because adequate screening can lead to a lower mortality. Remember that self-collection is an alternative for your patients, and it is FDA-approved if it is done in a healthcare setting. The ASCCP guidelines are very useful but difficult to memorize, so you can invest in the ASCCP phone app to provide accurate care for your patients. Thanks!References: 1. World Health Organization. HPV and Cervical Cancer Fact Sheet. 2024. Available online: https://www.who.int/en/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer (accessed on 10 August 2024).2. Arbyn M, Weiderpass E, Bruni L, et al. Estimates of incidence and mortality of cervical cancer in 2018: a worldwide analysis. Lancet Glob Health. 2020;8(2):e191-e203.3. Serrano B, Ibáñez R, Robles C, Peremiquel-Trillas P, de Sanjosé S, Bruni L. Worldwide use of HPV self-sampling for cervical cancer screening. Preventive Medicine. 2022;154:106900.4. Gupta S, Palmer C, Bik EM, et al. Self-sampling for human papillomavirus testing: increased cervical cancer screening participation and incorporation in international screening programs. Front Public Health. 2018;6:345033.5. Ubah C, Nwaneri AC, Anarado AN, Iheanacho PN, Odikpo LC. Perceived barriers to cervical cancer screening uptake among women of an urban community in South-eastern Nigeria. Asian Pac J Cancer Prev. 2022;23(6):1959-1965.6. Vega Crespo, B., Neira, V.A., Ortíz Segarra, J. et al.Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals. BMC Public Health 22, 2144 (2022). https://doi.org/10.1186/s12889-022-14601-y7.Olaza-Maguiña AF, De la Cruz-Ramirez YM. Barriers to the non-acceptance of cervical cancer screenings (Pap smear test) in women of childbearing age in a rural area of Peru. Ecancermedicalscience. 2019;13:901.8. Sharma M, Batra K, Johansen C, Raich S. Explaining correlates of cervical cancer screening among minority women in the United States. Pharmacy. 2022 Feb 15;10(1):30.9. Polman NJ, Ebisch RMF, Heideman DAM, et al. Performance of human papillomavirus testing on self-collected versus clinician-collected samples for the detection of cervical intraepithelial neoplasia of grade 2 or worse: a randomised, paired screen-positive, non-inferiority trial. The Lancet Oncology. 2019;20(2):229-238.10. Costa S, Verberckmoes B, Castle PE, Arbyn M. Offering HPV self-sampling kits: an updated meta-analysis of the effectiveness of strategies to increase participation in cervical cancer screening. British Journal of Cancer. 2023 Mar 23;128(5):805-13.11. Perkins RB, Guido RS, Castle PE, et al. 2019 ASCCP risk-based management consensus guidelines for abnormal cervical cancer screening tests and cancer precursors. J Low Genit Tract Dis. 2020;24(2):102-131.12. Straughn, Jr, J Michael, and Catheryn Yashar. “Management of Early-Stage Cervical Cancer.” Www.uptodate.com, 2 Aug. 2024, https://www.uptodate.com/contents/management-of-early-stage-cervical-cancer. Accessed 13 Aug. 2024.13. AMBOSS GmbH.Cervical cancer screening. https://amboss.com/. Accessed August 18, 2024.14. Royalty-free music used for this episode: Lofi-Chilly by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 175: Alcohol Use Disorder Basics   Future Dr. Sangha explains the clinical presentation, diagnosis, and fundamentals of the treatment of alcohol use disorder (AUD). Dr. Arreaza offers insights about the human aspect of the treatment of AUD.    Written by Darshpreet Sangha, MS4, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is Alcohol Use Disorder?AUD is characterized as the inability to stop or control alcohol use despite adverse physical, social and occupational consequences. According to DSM-5, it is a pattern of alcohol use that, over 12 months, results in at least two of the following symptoms, indicating clinically substantial impairment or distress: Alcohol is frequently used in higher quantities or for longer periods than planned.There is a persistent desire or unsuccessful attempt to reduce or manage alcohol use.Activities that are required to get alcohol, consume alcohol, or recuperate from its effects take up a lot of time.A strong need or desire to consume alcohol—a craving.A pattern of drinking alcohol that prevents one from carrying out important responsibilities at work, school, or home.Sustained alcohol consumption despite ongoing or recurring interpersonal or social issues brought on by or made worse by alcohol's effects.Alcohol usage results in the reduction or cessation of important social, professional, or leisure activities.Frequent consumption of alcohol under risky physical circumstances.Continuing to drink even when one is aware of a chronic or recurrent health or psychological issue that may have been brought on by or made worse by alcoholTolerance: requiring significantly higher alcohol intake to produce the same intended effect. Withdrawal: Characterized by the typical withdrawal symptoms or a noticing relief after taking alcohol or a closely related substance, such as benzodiazepine.How can we determine the severity of AUD? Mild: 2–3 symptomsModerate: 4–5 symptomsSevere: >/= 6 symptomsWho is at risk for AUD?Note: Ancestry offers a DNA analysis to find out about your heritage. You can also send that DNA to a third party to learn about your risks for diseases and conditions (for example, Prometheus.) Anyone can find out about their risk for alcoholism by doing a DNA test. The risk factors for AUD are: Male genderAges 18-29Native American and White ethnicitiesHaving Significant disabilityHaving other substance use disorderMood disorder (MDD, Bipolar)Personality disorder (borderline, antisocial personality)What is heavy drinking?According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), heavy alcohol use is characterized as: Males who drink > 4 drinks daily or > 14 drinks per week Females who drink > 3 drinks on any given day or > 7 drinks per weekPathophysiology of AUD.The pathogenesis of AUD is not well understood, but factors that may play a role are genetics, environmental influences, personality traits, and cognitive functioning. Also, genetic factors may decrease the risk of AUD, i.e., the flushing reaction, seen in individuals who are homozygous for the gene that encodes for aldehyde dehydrogenase, which breaks down acetaldehyde. Who should be screened?A person with AUD may not be easy to diagnose in a simple office visit, but some clues may point you in that direction. First of all, patients with AUD may present to you during their sober state, that´s why ALL adults (including pregnant patients) must be screened for AUD in primary care )Grade B recommendation). The frequency has not been determined but as a general rule, at least in Clinica Sierra Vista, we screen once a year. The USPSTF has concluded that there is insufficient evidence to recommend screening adolescents between 12-17 years old. What are the clinical manifestations of AUD?Some symptoms may be subtle, including sleep disturbance, GERD, HTN, but some may be obvious, such as signs of advanced liver disease (ascites, jaundice, bleeding disorders, etc.)If you draw routine labs, you may find abnormal LFTs (AST:ALT ratio >2:1), macrocytic anemia (MCV >100 fL), and elevated Gamma-glutamyl transferase (GGT). All these findings are highly suggestive of AUD. Patients with AUD may present in either an intoxication or withdrawal state. Signs and symptoms of acute intoxication may include “slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, hypotension, tachycardia, memory impairment, stupor, or coma.” Signs and symptoms of withdrawal range from tremulousness to hallucinations, seizures, and death. They are seen between 4 and 72 hours after the last drink, peaking at 48 hours, and can last up to 5 days. Alcohol withdrawal is one of the few fatal withdrawal syndromes that we know in medicine, and the symptoms can be assessed using a CIWA assessment. Treatment of AUD.There are factors to consider before starting treatment: Evaluating the severity of AUD Establishing clear treatment goals is associated with better treatment outcomesAssessing readiness to change: It can be done by motivational interviewing and using the stages of change model, which are, Pre-contemplation, contemplation, preparation, action, maintenance, and relapse.Discussing treatment of withdrawal.Treatment may be done as outpatient or it may require hospitalization. Dr. Beare sent an email with this information: “The approach to treating patients with AUD can be broken into two parts - the first is withdrawal management and the second is the long-term maintenance part. You MUST have a good plan for withdrawal treatment as it can be fatal if it's not addressed properly.” “Patients with any history of seizures due to withdrawal or a history of delirium tremens need inpatient management. If their withdrawal symptoms are typically mild (agitation, tremors, sleeplessness, anxiety) then outpatient management may be appropriate, typically with a long-acting benzodiazepine such as Librium or Ativan.”According to Dr. Beare, “the human aspect isa key element in treating alcohol use disorder. These patients arrive with tremendous amounts of suffering, shame, guilt, and fear. The relationship between the patient and provider needs to be built with compassion and understanding that this disease is horrible from the patient's perspective and using an algorithmic and calculated approach can cause significant harm to the rapport-building process, leading to lower success rates.”Treatment requires a lot of motivation and willpower. Hopefully, we can use some tools to assist our patients to be successful.-For mild disorder, Psychosocial interventions like motivational interviewing and mutual help groups like AA meetings may be enough to help our patient quit drinking.-For moderate or severe disorder: 1st line treatment is Meditation and structured, evidence-based psychosocial interventions (CBT, 12-step facilitation); which leads to better outcomesFor patients who lack motivation, motivational interviewing can be a useful initial interventionFor motivated patients: medical management, combined behavioral intervention, or a combination of both can be utilizedFor patients with limited cognitive abilities, 12-step facilitation, or contingency management can be helpful For patients who have an involved partner: Behavioral couples therapy can be utilizedMedications for AUD.The first-line pharmacological treatment is Naltrexone. It is given as a daily single dose and can be started while the patient is still actively drinking. There is a monthly dose of long-acting injectable naltrexone as well. Naltrexone is contraindicated in individuals taking opioids, and patients with acute hepatitis or hepatic failure. Alternative 1st line treatment is Acamprosate which can be used in people with contraindications to Naltrexone.AUD is a chronic problem and requires a close follow-up to evaluate response to treatment and complications. Medications need to be used along with psychotherapy and support, and medications may need to be changed or adjusted depending on the patient. It is an individualized therapy that requires full engagement of the doctor, the patient, and their families or social support. In conclusion, I would just like to add that, be compassionate because AUD is not a choice. AUD is a chronic problem like diabetes and HTN and may require a long road to recovery. Treatment includes psychotherapy, medications, and regular follow-up.Thank you for listening!Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment, https://www.uptodate.com/contents/risky-drinking-and-alcohol-use-disorder-epidemiology-clinical-features-adverse-consequences-screening-and-assessment, accessed on August 18, 2024.Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry, Accessed on August 18, 2024.Alcohol use disorder: Treatment overview, https://www.uptodate.com/contents/alcohol-use-disorder-treatment-overview, assessed on August 18, 2024. Royalty-free music used for this episode, Grande Hip-Hop by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 174: GERD in AdultsCommon and atypical symptoms are presented. Pathophysiology, diagnosis, and management are discussed. H. pylori's role is discussed during this episode. Written by Jacquelyn Garcia MS4 Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definitions: Gastroesophageal reflux (GER): occasional backflow of stomach acid into the esophagus. It's a common physiological process that happens to many people, especially after meals. Occurs less than twice a week. Associated with mild and temporary symptoms such as heartburn or regurgitation. Gastroesophageal reflux disease (GERD): a chronic and more severe form of GER. It occurs when acid reflux happens frequently, typically more than twice a week, and/or causes esophageal injury/complications. -Non-erosive reflux disease (NERD)= GER without evidence of esophageal injury on endoscopy. -Erosive reflux disease (ERD)= GER with evidence of esophageal injury on endoscopy.AFP Journal, January 2024: “Nonerosive GERD does not increase the likelihood of esophageal cancer. However, erosive GERD is associated with a doubled, but still low, risk of developing cancer, with the likelihood increasing over time.”Pathophysiology:The main pathophysiology behind GERD is lower esophageal sphincter (LES) dysfunction which can occur due to the following:-LES Pressure: The LES is a muscular ring at the junction of the esophagus and stomach. It normally maintains a high-pressure zone to prevent reflux. In GERD, the intragastric pressure is higher than the pressure created by the LES. The tone of the LES can be reduced by caffeine, nitroglycerin, and scleroderma. -Transient LES Relaxations (TLESRs): These are normal relaxations of the LES that occur independently of swallowing. In GERD, these relaxations are more frequent or prolonged, allowing acid to reflux into the esophagus.-Anatomic abnormalities: A hiatal hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. This disrupts the normal anatomy of the gastroesophageal junction, reducing the pressure barrier and promoting reflux.Epidemiology: It affects 10-20% of adults in Western cultures and less than 5% in Asia. Prevalence in the US ranges from 18.1% to 27.8% with a slightly higher rate in men. Risk factors: -Obesity, pregnancy, scleroderma, hiatal hernia; smoking, caffeine, alcohol, stress, fatty/fried/spicy foods. Spicy foods can be a challenge in some cultures (e.g. Mexican and Indian.) Sometimes, patients may ask for “something” to stop GERD but all they may need is dietary modification. -Medications: -aspirin, ibuprofen, clindamycin, tetracycline, bisphosphonates (irritate the esophagus and cause heartburn pain similar to GERD) -anticholinergics, TCA’s, CCB’s, ACEi, statins, benzodiazepines, theophylline, opioids, progesterone (increase acid reflux and worsen GERD)Clinical features: Typical symptoms: -heartburn (burning retrosternal pain) -regurgitation (acidic stomach contents)Atypical symptoms: -chest pain (can mimic angina pectoris, squeezing/burning substernal, radiates to back/neck/jaw/arm) -water brash (hypersalivation)-globus sensation (lump in throat)-nausea -belching-bloating Alarm features in GERD: -dysphagia-odynophagia (pain with swallowing)-new onset of dyspepsia in ≥60yo -weight loss-GI bleeding-vomiting-anemia Diagnosis: -There is no gold standard test -Patient with typical symptoms: diagnosis can be based on clinical symptoms alone -Patient with atypical symptoms: these symptoms can be seen in GERD but are not sufficient for diagnosis of GERD in the absence of typical symptoms. Need to rule out other disorders before associating the symptoms with GERD. (ex: chest pain r/o other causes such as MI with ECG) -Patient with alarm features: refer to GI for upper GI endoscopy. Complications: -Esophagitis: Erosive reflux disease (ERD) = GER with evidence of esophageal distal injury on endoscopy; in untreated GERD 30% have esophagitis. -Iron deficiency anemia: due to mucosal ulcerations -> chronic bleeding.-Esophageal stricture: narrowing near GE junction, solid food dysphagia.-Barrett Esophagus: intestinal metaplasia of esophagus due to chronic GERD (stratified squamous epithelium replaced by columnar epithelium)-Risk factors: GERD for 5-10 years, >50yo, males, obesity, Caucasian, Tobacco use, family history                 -Predisposes to esophageal adenocarcinoma Role of H. pylori.Sometimes we tend to think that H. pylori is the cause of GERD. “H. pylori infection appears to protect the esophagus from gastroesophageal reflux disease, Barrett's esophagus, dysplasia in Barrett's esophagus, and esophageal adenocarcinoma, perhaps by causing chronic gastritis that interferes with acid production.”It is unclear whether long-term use of PPIs heightens the risk of atrophic gastritis in patients with H. pylori. Consequently, routine screening for H. pylori infection and empiric eradication of H. pylori are NOT advised for patients with GERD. However, if H. pylori is diagnosed in the setting of GERD, eradication of H. pylori has been associated with an improvement of symptoms in patients with antral-predominant gastritis. Treatment: Two categories: Mild/intermittent symptoms (“Step up approach”1. Lifestyle modifications (weight loss, elevation of head of bed if have nighttime symptoms, diet modification/elimination of triggers) and low dose histamine 2 receptor antagonists or H2RA (famotidine, nizatidine, cimetidine) PRN for 4 weeks; antacids if symptoms 2. Symptoms persistà standard dose H2RA BID for 2 weeks 3. Symptoms persistà low dose PPI (omeprazole, pantoprazole, esomeprazole) qd for 4-8 weeks 4. Symptoms persistà standard dose PPI qd for 4-8 weeks 5. Symptoms persistà refractory GERD txArreaza: What if the symptoms improve? -Symptoms improved on PPIà taper and discontinue PPI if asymptomatic for 8 weeks (do not do if have erosive esophagitis or Barrett’s) -Symptoms improved on H2RA à continue as PRN + lifestyle modifications Arreaza: What if symptoms come back?-Recurrent symptoms ≥3months of discontinuing meds: resume previous therapy for 8 weeks-Recurrent symptoms within 3 months of discontinuing meds: upper GI endoscopy and long-term maintenance therapy Jacquelyn:Severe/frequent symptoms (≥2 times per week), ERD, Barrett’s esophagus “Step down approach”1. Lifestyle modifications AND standard dose PPI qd for 4-8 weeks.2. Symptoms persistà refractory GERD tx Refractory GERD tx:1. Discuss with pt med compliance and usage2. Symptoms persistà different PPI for 8 weeks or PPI BID for 8 weeks 3. Symptoms persistà upper GI endoscopyAlarm features: upper GI endoscopy. The Choosing Wisely campaign recommends that you discuss stopping PPI every year with your patient because PPIs are not free of harms.PPI adverse effects: associated with increased risk of C. diff according to FDA safety announcement in 2012. Even without recent antibiotic use. So, patients may have to switch to another alternative due to this adverse effect of PPIs. -others: GI upset (nausea, diarrhea, and abdominal pain), decreased iron, B12, calcium, and magnesium absorption (FDA 2010 advises possible increased risk of fractures in elderly).PPIs were a breakthrough medication in 1989, before that time, people got surgery for gastritis, but over time PPIs became popular, but they can be a double-edged sword, it is excellent for symptom control at the expense of potential short- and long-term side effects. -Other treatment options if there is no improvement with medical management, if a large hiatal hernia is present, or if complications occur despite medical therapy, surgical treatment is recommended. Conclusion: GERD is very common in our clinics/hospitals. It is important to recognize classic symptoms and differentiate symptoms from mild to severe. We need to start treatment and refer to GI promptly. Primary care is in a special position in evaluating these patients so we can avoid them developing potential complications like cancer. ______________________Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! References:El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastroesophageal reflux disease: a systematic review. Gut. 2014;63(6):871–880. doi: 10.1136/gutjnl-2012-304269  https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-factsFass, Ronnie, et al. Approach to refractory gastroesophageal reflux disease in adults, Up to Date, last updated: May 14, 2024. https://www.uptodate.com/contents/approach-to-refractory-gastroesophageal-reflux-disease-in-adults. Kahrilas, Peter, et al. Medical management of gastroesophageal reflux disease in adults, Up to Date, last updated: Sep 19, 2022. https://www.uptodate.com/contents/medical-management-of-gastroesophageal-reflux-disease-in-adults.Kahrilas, Peter, et al. Clinical manifestations and diagnosis of gastroesophageal reflux in adults, Up to Date, last updated Jul 15, 2022. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gastroesophageal-reflux-in-adults.Kahrilas, Peter, et all. Pathophysiology of gastroesophageal reflux disease, Up to Date, last updated: May 22, 2024. https://www.uptodate.com/contents/pathophysiology-of-gastroesophageal-reflux-disease.Schwaitzberg, Steven D, Surgical treatment of gastroesophageal reflux in adults, Up to Date, last updated: Sep 27, 2023. https://www-uptodate-com/contents/surgical-treatment-of-gastroesophageal-reflux-in-adults. Shaqran TM, Ismaeel MM, Alnuaman AA, et al. Epidemiology, Causes, and Management of Gastro-esophageal Reflux Disease: A Systematic Review. Cureus. 2023;15(10):e47420. Published 2023 Oct 21. doi:10.7759/cureus.47420. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10658748/Spechler, Stuart J, et al. Barrett's esophagus: Epidemiology, clinical manifestations, and diagnosis, Up to Date, last updated: Apr 30, 2024. https://www.uptodate.com/contents/barretts-esophagus-epidemiology-clinical-manifestations-and-diagnosis.Shaughnessy AF. No Increased Risk of Esophageal Cancer With Nonerosive Gastroesophageal Reflux. Am Fam Physician. 2024;109(1):. https://pubmed.ncbi.nlm.nih.gov/38227884/U.S. Food and Drug Administration. (2012). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs).  https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-clostridium-difficile-associated-diarrhea-can-be-associated-stomach. Wolf, Michael M et al. Proton pump inhibitors: Overview of use and adverse effects in the treatment of acid related disorders, Up to Date, last updated: May 31, 2024. https://www.uptodate.com/contents/proton-pump-inhibitors-overview-of-use-and-adverse-effects-in-the-treatment-of-acid-related-disorders.Royalty-free music used for this episode: Milkshake by Gushito, downloaded on July 20, 2023, from https://www.videvo.net 

Episode 173: Acute OsteomyelitisFuture Dr. Tran explains the pathophysiology of osteomyelitis and describes the presentation, diagnosis and management of acute osteomyelitis. Dr. Arreaza provides information about    Written by Di Tran, MSIII, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is osteomyelitis?Osteomyelitis, in simple terms, is an infectious disease that affects both bone and bone marrow and is either acute or chronic.  According to archaeological findings of animal fossils with a bone infection, osteomyelitis was more than likely to be known as a “disease for old individuals”.Our ancestors over the years have used various vocabulary terms to describe this disease until a French surgeon, Dr. Nelaton, came up with the term “Osteomyelitis” in 1844. This is the beauty of medical terms, Latin sounds complicated for some people, but if you break up the term, it makes sense: Osteo = bone, myelo = marrow, itis = inflammation. So, inflammation of the bone marrow.Traditionally, osteomyelitis develops from 3 different sources:First category is the “hematOgenous” spread of the infection within the bloodstream, as in bacteremia. It is more frequent in children and long bones are usually affected. [Arreaza: it means that the infection started somewhere else but it got “planted” in the bones]Second route is “direct inoculation” of bacteria from the contiguous site of infection “without vascular insufficiency”, or trauma, which may occur secondary to fractures or surgery in adults.  In elderly patients, the infection may be related to decubitus ulcers and joint replacements.And the third route is the “contiguous” infection “with vascular insufficiency”, most seen in a patient with a diabetic foot infection.Patients with vascular insufficiency often have compromised blood supply to the lower extremities, and poor circulation impairs healing. In these situations, infection often occurs in small bones of the feet with minimal to no pain due to neuropathy.They can have ulcers, as well as paronychia, cellulitis, or puncture wounds.Thus, the importance of treating onychomycosis in diabetes because the fungus does not cause a lot of problems by itself, but it can cause breaks in the nails that can be a port of entry for bacteria to cause severe infections. Neuropathy is an important risk factor because of the loss of protective sensation. Frequently, patients may step on a foreign object and not feel it until there is swelling, purulent discharge, and redness, and they come to you because it “does not look good.”Acute osteomyelitis often takes place within 2 weeks of onset of the disease, and the main histopathological findings are microorganisms, congested blood vessels, and polymorphonuclear leukocytes, or neutrophilic infiltrates.What are the bugs that cause osteomyelitis?Pathogens in osteomyelitis are heavily depended on the patient’s age.  Staph. aureus is the most common culprit of acute hematogenous osteomyelitis in children and adults.  Then comes Group A Strep., Strep. pneumoniae, Pseudomonas, Kingella, and methicillin-resistant Staph. aureus.  In newborns, we have Group B Streptococcal. Less common pathogens are associated with certain clinical presentations, including Aspergillus, Mycobacterium tuberculosis, and Candida in the immunocompromised.Salmonella species can be found in patients with sickle cell disease, Bartonella species in patients with HIV infection, and Pasteurella or Eikenella species from human or animal bites.It is important to gather a complete medical history of the patient, such as disorders that may put them at risk of osteomyelitis, such as diabetes, malnutrition, smoking, peripheral or coronary artery disease, immune deficiencies, IV drug use, prosthetic joints, cancer, and even sickle cell anemia. Those pieces of information can guide your assessment and plan.What is the presentation of osteomyelitis?Acute osteomyelitis may present symptoms over a few days from onset of infection but usually is within a 2-week window period.  Adults will develop local symptoms of erythema, swelling, warmth, and dull pain at the site of infection with or without systemic symptoms of fever or chills.Children will also be present with lethargy or irritability in addition to the symptoms already mentioned.It may be challenging to diagnose osteomyelitis at the early stages of infection, but you must have a high level of suspicion in patients with high risks. A thorough physical examination sometimes will show other significant findings of soft tissue infection, bony tenderness, joint effusion, decreased ROM, and even exposed bone. Diagnosis.As a rule of thumb, the gold standard for the diagnosis of osteomyelitis is bone biopsy with histopathology findings and tissue culture. There is leukocytosis, but then WBC counts can be normal even in the setting of acute osteomyelitis.Inflammatory markers (CRP, ESR) are often elevated although both have very low specificity. Blood cultures should always be obtained whenever osteomyelitis is suspected.  A bone biopsy should also be performed for definitive diagnosis, and specimens should undergo both aerobic and anaerobic cultures.  In cases of osteomyelitis from diabetic foot infection, do the “probe to bone” test. What we do is we use a sterile steel probe to detect bone which is helpful for osteomyelitis confirmation.Something that we can’t miss out on is radiographic imaging, which is quite important for the evaluation of osteomyelitis.  Several modalities are useful and can be used for the work-up plan; plain radiographs often are the very first step in the assessment due to their feasibility, low cost, and safety.  Others are bone scintigraphy, CT-scan, and MRI.  In fact, the MRI is widely used and provides better information for early detection of osteomyelitis than other imaging modalities.  It can detect necrotic bone, sinus tracts, and even abscesses. We look for soft tissue swelling, cortical bone loss, active bone resorption and remodeling, and periosteal reaction.  Oftentimes, plain radiography and MRI are used in combination. Treatment:Treatment of osteomyelitis actually is a teamwork effort among various medical professionals, including the primary care provider, the radiologist, the vascular, the pharmacist, the podiatrist, an infectious disease specialist, orthopedic surgeons, and the wound care team.Something to take into consideration, if the patient is hemodynamically stable it is highly recommended to delay empirical antibiotic treatment 48-72 hours until a bone biopsy is obtained.  The reason is that with percutaneous biopsy ideally done before the initiation of antibiotic treatment, “the microbiological yield will be higher”.We’ll have a better idea of what particular bugs are causing the problem and guide the treatment appropriately. The choice of antibiotic therapy is strongly determined by susceptibilities results.  The antibiotic given will be narrowed down only for the targeted susceptible organisms.  In the absence of such information, or when a hospitalized patient presents with an increased risk for MRSA infection, empiric antibiotic coverage is then administered while awaiting culture results. It should be broad-spectrum antibiotics and include coverage for MRSA, broad gram-negative and anaerobic bacteria.  For example, vancomycin plus piperacillin-tazobactam, or with broad-spectrum cephalosporin plus clindamycin.  Treatment will typically be given for 4 to 6 weeks.The duration between 4-6 weeks is important for complete healing, but a small study with a small sample showed that an even shorter duration of 3 weeks may be effective, but more research is needed. In certain situations, surgery is necessary to preserve viable tissue and prevent recurrent infection, especially when there are deep abscesses, necrosis, or gangrene, amputation or debridement is deemed appropriate. If the infected bone is completely removed, patients may need a shorter course of antibiotics, even a few days only. Amputation can be very distressing, especially when we need to remove large pieces of infected bone, for example, a below-the-knee amputation. We need to be sensitive to the patient’s feelings and make a shared decision about the best treatment for them.In patients with diabetes, additional care must be taken seriously, patient education about the need for compliance with treatment recommendations, with careful wound care, and good glycemic control are all beneficial for the healing and recovery process. Because this is a very common problem in the clinic and at the hospital, we must keep our eyes wide open and carefully assess patients with suspected osteomyelitis to detect it promptly and start appropriate treatment. Adequate and timely treatment is linked to fewer complications and better outcomes._________________________Conclusion: Now we conclude episode number 173, “Acute Osteomyelitis.” Future Dr. Tran explained the pathophysiology, diagnosis, and management of osteomyelitis. A bone biopsy is the ideal method of diagnosis. Delaying antibiotic treatment a few days until you get a biopsy is allowed if the patient is stable, but if the patient is unstable, antibiotics must be started promptly. Dr. Arreaza mentioned the implications of amputation and that we must discuss this treatment empathically with our patients. This week we thank Hector Arreaza and Di Tran. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Bury DC, Rogers TS, Dickman MM. Osteomyelitis: Diagnosis and Treatment. Am Fam Physician. 2021 Oct 1;104(4):395-402. PMID: 34652112.Cunha BA. Osteomyelitis in elderly patients. Clin Infect Dis. 2002 Aug 1;35(3):287-93. doi: 10.1086/341417. Epub 2002 Jul 11. PMID: 12115094.Fritz JM, McDonald JR. Osteomyelitis: approach to diagnosis and treatment. Phys Sportsmed. 2008 Dec;36(1):nihpa116823. doi: 10.3810/psm.2008.12.11. PMID: 19652694; PMCID: PMC2696389.Hatzenbuehler J, Pulling TJ. Diagnosis and management of osteomyelitis. Am Fam Physician. 2011 Nov 1;84(9):1027-33. PMID: 22046943.Hofstee MI, Muthukrishnan G, Atkins GJ, Riool M, Thompson K, Morgenstern M, Stoddart MJ, Richards RG, Zaat SAJ, Moriarty TF. Current Concepts of Osteomyelitis: From Pathologic Mechanisms to Advanced Research Methods. Am J Pathol. 2020 Jun;190(6):1151-1163. doi: 10.1016/j.ajpath.2020.02.007. Epub 2020 Mar 16. PMID: 32194053.Momodu II, Savaliya V. Osteomyelitis. [Updated 2023 May 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532250/Royalty-free music used for this episode: Trap Chiller by Gushito, downloaded on Nov 06, 2023, from https://www.videvo.net 

Episode 172: NAFLD and ObesityFuture Dr. Nguyen explains the pathophysiology of non-alcoholic fatty liver disease and how it relates to obesity. Dr. Arreaza gives information about screening and diagnosis of NAFLD. Written by Ryan Nguyen, MS4, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction/PathophysiologyNonalcoholic fatty liver disease (NAFLD) refers to the buildup of excess fat in liver cells, occurring without the influence of alcohol or drugs. Nonalcoholic steatohepatitis (NASH) represents a more severe form of NAFLD, characterized by inflammation and liver cell injury due to fat accumulation. If left untreated, NASH can progress to liver fibrosis or cirrhosis. Typically, NAFLD/NASH is diagnosed after other liver conditions are ruled out, making it a diagnosis of exclusion.NAFLD -> NASH -> Cirrhosis -> Liver failure. Another term for NAFLD is metabolic dysfunction-associated steatotic liver disease. Fatty liver disease is identified when more than 5% of liver weight consists of fat, whereas, NASH is diagnosed when this fat accumulation is accompanied by inflammation and liver cell injury, sometimes leading to fibrosis. Understanding these distinctions is crucial in recognizing and managing the spectrum of liver conditions associated with obesity and metabolic syndrome.BMI serves as a tool to gauge body fat levels: individuals are categorized as normal weight if their BMI falls between 18.5 and 24.9, overweight if it ranges from 25 to 29.9. Class I obesity is diagnosed with a BMI of 30 to 34.9, class II obesity between 35 and 39.9, and class III obesity when BMI exceeds 40.Obesity puts you at risk of NAFLD, but you can also see NAFLD in non-obese patients, but the prevalence is very low, about 5%. What did you learn about the demographics of NAFLD?NAFLD is most widespread in regions like South Asia, the Middle East, Mexico, Central and South America, with prevalence rates exceeding 30%. In the United States, prevalence varies with approximately 23-27%, notably higher among Asians at 30%, followed by Hispanic individuals at 21%, White individuals at 12.5%, and Black individuals at 11.6%. Across all racial groups, obesity plays a significant role, affecting more than two-thirds of individuals diagnosed with NAFLD. Understanding these demographics underscores the global impact of obesity on NAFLD prevalence.Diagnosis: Screening/Labs/Imaging/ToolsThe American Association for the Study of Liver Diseases does not recommend screening for NAFLD, but if it is discovered an appropriate workup is warranted. AST/ALT RatioLiver health can be assessed by a series of tests aimed at assessing fat accumulation, inflammation, and fibrosis. Initial screening often includes laboratory tests such as measuring the ratio between aspartate transaminase (AST) and alanine transaminase (ALT), where a ratio less than 1 may suggest possible NAFLD, although it is not diagnostic on its own. Normally, AST is slightly more elevated than ALT. So, if the AST/ALT ratio is lower, then means that ALT is higher than AST. FibroSure®.Additionally, you can measure indirect markers of fibrosis with tests such as FibroSure or FibroTest blood tests that combine several biomarkers including age, sex, gamma-glutamyl-transferase (GGT), total bilirubin, alpha-2-macroglobulin, apolipoprotein A1, haptoglobin, and ALT to provide insights into liver health.Some people may be more familiar with FibroSure before Hepatitis C treatment. You can get a fibrosis score (F0-F4), and it is considered significant fibrosis if the score is > or equal to F2. Imaging plays a crucial role in diagnosing NAFLD without the need for invasive procedures like liver biopsy. Vibration-controlled transient elastography (Fibroscan) uses ultrasound to measure liver stiffness, indicating potential fibrosis and inflammation. While noninvasive and portable, it focuses solely on liver ultrasound and may not be universally accessible. MRI with proton density fat fraction (MRI-PDFF) offers a comprehensive assessment of liver fat content, commonly used in clinical and research settings for NAFLD and NASH evaluation.For evaluating hepatic fibrosis in patients with suspected NAFLD, tools like the Fibrosis-4 Index (FIB-4) incorporate age, AST, ALT, and platelet count to estimate the likelihood of liver disease progression. These screening methods collectively aid in diagnosing and monitoring NAFLD, particularly in individuals at risk due to factors like prediabetes, type 2 diabetes, obesity, and abnormal liver enzyme ratios. With the FIB-4 you can get a faster answer than FibroSure because you only need 4 elements: Age, platelet count, AST and ALT. Cirrhosis is less likely if FIB-4 is 3.25. Understanding these diagnostic approaches is essential for early detection and management of NAFLD in clinical practice.Some researchers are invested in diagnosis and treating NAFLD while others recommend against labeling patients with NAFLD. A 2018 Lancet article concluded that the risks of over-diagnosing and overtreating NAFLD exceed the benefits of screening or periodic imaging because of “the low hepatic mortality, high false-positive rate of ultrasonography, selection bias of current studies, and lack of viable treatment.” However, patients who suffer from metabolic syndrome should be counseled about dietary modification and physical activity regardless of their liver condition. NAFLD and obesityFatty liver disease is often caused by multiple insults towards either genetically or environmentally predisposed individuals. Family history of NAFLD and having specific genetic variants are important risk factors for NAFLD. Those with prior health conditions can have increased susceptibility to NAFLD including T2DM leading to insulin resistance, metabolic syndrome, sleep apnea, hepatitis C, and cardiovascular or chronic kidney disease. A sedentary lifestyle and unhealthy nutrition (especially high intake of processed carbohydrates) cause an increase in free fatty acids leading to hepatic fat deposition → ballooning of hepatocytes → leading to hepatocyte injury/death → inflammation with fibroblast recruitment → end result of fibrosis/cirrhosis. Just a quick reminder, NAFLD is defined as fatty liver with >5% hepatic fat and NASH is defined as fatty liver with >5% hepatic fat with inflammation, hepatocyte injury, with or without fibrosis that we can determine through imaging. A leading concern for the development of NAFLD is the consumption of high fructose corn syrup.  High fructose corn syrup (HFCS), commonly found in candy, processed sweets, soda, fruit juices, and other processed foods, is linked to non-alcoholic fatty liver disease (NAFLD). Unlike natural whole fruits, which contain fiber and are generally healthier due to their slower absorption, HFCS lacks fiber and is quickly absorbed, leading to rapid transport to the liver. This process contributes to NAFLD by increasing the hepatic synthesis of lipids and interfering with insulin signaling. To avoid HFCS, individuals are encouraged to consume whole fruits rather than fruit juices and adopt diets rich in whole grains, lean meats, plant-based proteins, fruits, and vegetables, such as the Mediterranean or DASH diets, which are less likely to promote NAFLD, especially in those with healthy body weight.NAFLD treatment.Avoiding alcohol seems very obvious, but we need to mention it. Avoiding heavy alcohol consumption is recommended and complete abstinence is suggested.Weight loss is crucial; even a modest reduction of 3–5% in body weight can alleviate hepatic steatosis, with greater improvements typically seen with 7–10% weight loss, particularly beneficial for addressing histopathological features of NASH, such as fibrosis. We must focus on tailored medical nutrition therapy and regular physical activity. A strategic meal plan is essential, emphasizing achieving a healthy body weight while limiting trans fats and ultra-processed carbohydrates. Options like the Mediterranean diet, which balances lean proteins and restricts processed carbohydrates have shown promise. Dynamic aerobic and resistance exercises play a significant role in managing NAFLD. They help maintain a healthy weight and enhance peripheral insulin sensitivity, reduce circulating free fatty acids and glucose levels, and boost intrahepatic fatty acid oxidation while curbing fatty acid synthesis. These benefits contribute to mitigating liver damage associated with NAFLD, offering therapeutic advantages beyond mere weight reduction.Exercise may not be a great tool for weight loss, but it is a great tool for weight maintenance, liver health, and overall health as well. “Most patients with NAFLD die from vascular causes, but NAFLD puts patients at increased risk of cardiovascular death”. Medications for NAFLD.Regarding pharmacotherapy, while no medications are currently FDA-approved specifically for NAFLD treatment, some options show promise in clinical settings. Vitamin E supplementation at 800 IU (international units) daily has demonstrated biochemical and histological improvements in NASH cases without diabetes or cirrhosis, though long-term use may elevate prostate cancer risks. It is important to make a shared decision with the patient before starting Vitamin E supplementation. Medications like pioglitazone can reduce liver fat and improve NASH, even as they may increase body weight. But our favorite, GLP-1 receptor agonists, such as liraglutide and semaglutide, also show potential in reducing liver fat and improving NASH symptoms, and this is an emerging therapeutic option for managing this condition.If you decide to treat, then you should monitor as part of the treatment. An aminotransferase check is recommended 6 months after starting a weight loss program. If levels do not improve or do not return to normal after 5-7% of weight loss, another cause of elevated transaminases needs to be investigated.You also need to monitor fibrosis in patients with >F2. If fibrosis has been proven by liver biopsy, you can order FibroSure every 3-4 years. Having a fatty liver may be a red flag that your patient has a metabolic problem. If you discover it, start interventions that would benefit not only the liver but the whole metabolic profile of your patient. The Obesity Medicine Association (OMA) issued a Clinical Practice Statement (CPS) regarding NAFLD and obesity stating that patients with obesity are at increased risk for NAFLD and NASH. It recommends that clinicians strive to understand the etiology, diagnosis, and optimal treatment of NAFLD with a goal to prevent NASH in their patients.Regular exercise, even walking 30 minutes a day can show many benefits in curbing fatty accumulation in the liver. Having a proper diet with avoidance of high fructose corn syrup can overall help in reducing NAFLD/NASH. _____________________Conclusion: Now we conclude episode number 172, “NAFLD and Obesity.” Future Dr. Nguyen explained that NAFLD and obesity are closely related and NAFLD can lead to NASH and cirrhosis in some patients. Dr. Arreaza explained that screening may not be recommended by some medical societies, but others are in favor of screening and treating this disease. However, most people agree that NAFLD is a sign of metabolic disease and a good reason to talk about healthy eating and physical activity with our patients. There are no FDA-approved medications to treat NAFLD, but some evidence suggests that Vitamin E can improve it and GLP-1 receptor agonists are a promising option. This week we thank Hector Arreaza and Ryan Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Karjoo S, Auriemma A, Fraker T, Edward H. Nonalcoholic fatty liver disease and obesity: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022. https://doi.org/10.1016/j.obpill.2022.100027.Curry M, Afdhal N. Noninvasive assessment of hepatic fibrosis: Overview of serologic tests and imaging examinations.  https://www.uptodate.com/contents/noninvasive-assessment-of-hepatic-fibrosis-overview-of-serologic-tests-and-imaging-examinationsRoyalty-free music used for this episode: Cool Groove (Alt-Mix) by Videvo, downloaded on Nov 06, 2023, from https://www.videvo.net

Episode 171: Postpartum Blues, Depression, and PsychosisFuture Dr. Nguyen defines and explains the difference between baby blues, depression, and psychosis. Dr. Arreaza added comments about screening and management of these conditions. Written by Vy Nguyen, OMSIII, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction.Pregnancy is one of the most well-celebrated milestones in one’s life. However, once the baby is born, the focus of the family and society quickly shifts to the new member. It is important to continue to care for our mothers and offer them support physically and mentally as they begin their transition into their role. Peripartum mood disorders affect both new and experienced mothers as they navigate through the challenges of motherhood. The challenges of motherhood are not easy to spot, and they include sleep deprivation, physical exhaustion, dealing with pain, social isolation, and financial pressures, among other challenges. Let’s focus on 3 aspects of the postpartum period: Postpartum Blues (PPB), Post-partum Depression (PPD) and Post-partum Psychosis (PPP). By the way, we briefly touched on this topic in episode 20, a long time ago. Postpartum blues (PPB) present as transient and self-limiting low mood and mild depressive symptoms that affect more than 50% of women within two or three days of childbirth and resolve within two weeks of onset. Symptoms vary from crying, exhaustion, irritability, anxiety, appetite changes, and decreased sleep or concentration to mood lability. Women are at risk for PPB.Several factors are thought to contribute to the increased risk of postpartum blues including a history of menstrual cycle-related mood changes, mood changes associated with pregnancy, history of major depression, number of lifetime pregnancies, or family history of postpartum depression. Pathogenesis of PPB: While pathogenesis remains unknown, hormonal changes such as a dramatic decrease in estradiol, progesterone, and prolactin have been associated with the development of postpartum blues. In summary, PPB is equivalent to a brief, transient “sad feeling” after the delivery. Peripartum depression (PPD) occurs in 20% of women and is classified as depressive symptoms that appear within six weeks to 1 year after childbirth. Those with baby blues have an increased risk of developing postpartum depression. About 50% of “postpartum” major depressive episodes begin before delivery, thus the term has been updated from “postpartum” to “peripartum” depressive episodes. Some risk factors include adolescent patients, mothers who deliver premature infants, and women living in urban areas. Interestingly, African American and Hispanic mothers are reported to have onset of symptoms within two weeks of delivery instead of six like their Caucasian counterparts. Additional risks include psychological risks such as a personal history of depression, anxiety, premenstrual syndrome, and sexual abuse; obstetric risks such as emergency c-sections and hospitalizations, preterm or low birth infant, and low hemoglobin; social risks such as lack of social support, domestic violence in form of spousal physical/sexual/verbal abuse; lifestyle risks such as smoking, eating sleep patterns and physical activities. Peripartum depression can present with or without psychotic features, which may appear between 1 in 500 or 1 in 1,000 deliveries, more common in primiparous women. Pathogenesis of PPD: Much like postpartum blues, the pathogenesis of postpartum depression is unknown. However, it is known that hormones can interfere with the hypothalamic-pituitary-adrenal axis (HPA) and lactogenic hormones. HPA-releasing hormones increase during pregnancy and remain elevated up to 12 weeks postpartum. The body receptors in postpartum depression are susceptible to the drastic hormonal changes following childbirth which can trigger depressive symptoms. Low levels of oxytocin and prolactin also play a role in postpartum depression causing moms to have trouble with lactation around the onset of symptoms. The USPSTF recommends screening for depression in the adult population, including pregnant and postpartum persons, as well as older adults. Edinburgh Postnatal Depression Scale (EPDS) can be used in postpartum and pregnant persons (Grade B recommendation).Postpartum psychosis (PPP) is a psychiatric emergency that often presents with confusion, paranoia, delusions, disorganized thoughts, and hallucinations. Around 1-2 out of 1,000 new moms experience postpartum psychosis with the onset of symptoms as quickly as several days and as late as six weeks after childbirth. Given the high risk of suicide and harm, individuals with postpartum psychosis require immediate evaluation and treatment. Postpartum psychosis is considered multifactorial, and the single most important risk factor is first pregnancy with family or personal history of bipolar 1 disorder. Other risk factors include a prior history of postpartum psychosis, family history of psychosis, history of schizoaffective disorder or schizophrenia, or discontinuation of psychiatric medications. Studies show that patients with a history of decreased sleep due to manic episodes are twice as likely to have postpartum psychosis at some point in their lives. However, approximately 50% of mothers who experience psychosis for the first time do not have a history of psychiatric disorder or hospitalization. Evaluation.Symptoms of postpartum blues should not meet the criteria for a major depressive episode and should resolve in 2 weeks. The Edinburg Postpartum Depression Scale which is a useful tool for assessing new moms with depressive symptoms. Postpartum depression is diagnosed when the patient presents with at least five depressive symptoms for at least 2 weeks. According to the DSM5, postpartum depression is defined as a major depressive episode with peripartum onset of mood symptoms during pregnancy or in the 4 weeks following delivery. Symptoms for diagnosis include changes in sleep, interest, energy, concentration, appetite, psychomotor retardation or agitation, feeling of guilt or worthlessness, and suicidal ideation or attempt. These symptoms are not associated with a manic or hypomanic episode and can often lead to significant impediments in daily activities. Peripartum-onset mood episodes can present with or without psychotic features. The depression can be so severe that the mother commits infanticide. Infanticide can happen, for example, with command hallucinations or delusions that the infant is possessed.While there are no standard screening criteria in place of postpartum psychosis, questionnaires mentioned earlier such as the Edinburg Postpartum Depression Scale can assess a patient’s mood and identify signs of depression and mania. It is important after a thorough history and physical examination to order labs to rule out other medical conditions that can cause depressive and psychotic symptoms. Disorders like electrolyte imbalance, hepatic encephalopathy, thyroid storm, uremia, substance use, infections, and even stroke can mimic a psychiatric disorder. So, How can we treat patients who are diagnosed with a peripartum mood disorder?Management.On the spectrum of peripartum mood disorders, postpartum blues are the least severe and should be self-limiting by week 2. However, patients should be screened for suicidal ideation, paranoia, and homicidal ideation towards the newborn. Physicians should provide validation, education, and resources especially support with sleep and cognitive therapy and/or pharmacotherapy can be recommended if insomnia persists. Regarding postpartum depression, the first-line treatment includes psychotherapy and antidepressants. For those with mild to moderate depression or hesitant to start on medications, psychosocial and psychotherapy alone should be sufficient. However, for those with moderate to severe symptoms, a combination of therapy and antidepressants, such as selective serotonin reuptake inhibitors, is recommended. Once an effective dose is reached, patients should be treated for an additional 6 to 12 months to prevent relapse. In severe cases, patients may need to be hospitalized to treat their symptoms and prevent complications such as self-harm or infanticide.Most SSRIs can be detected in breast milk, but only 10 percent of the maternal level. Thus, they are considered safe during breastfeeding of healthy, full-term infants. So, you mentioned SSRIs, but also SNRIs, bupropion, and mirtazapine are reasonable options for treatment. In patients who have never been treated with antidepressants, zuranolone (a neuroactive steroid) is recommended. Zuranolone is easy to take, works fast, and is well tolerated. Treatment with zuranolone is consistent with practice guidelines from the American College of Obstetricians and Gynecologists.While there are no current guidelines to manage postpartum psychosis, immediate hospitalization is necessary in severe cases. Patients can be started on mood stabilizers such as lithium, valproate, and lamotrigine, and atypical antipsychotics such as quetiapine, and olanzapine, to name a few. Medications like lithium can be eliminated through breast milk and can expose infants to toxicity.The use of medications such as SSRIs, carbamazepine, valproate, and short-acting benzodiazepines are relatively safe and can be considered in those with plans to breastfeed. Ultimately, it is a decision that the patient can make after carefully discussing and weighing the pros and cons of the available medical management. While the prognosis of peripartum mood disorders is relatively good with many patients responding well to treatments, these disorders can have various negative consequences. Individuals with a history of postpartum blues are at increased risk of developing postpartum depression. Similarly, those with a history of postpartum psychosis are at risk of experiencing another episode of psychosis in future pregnancies. Additionally, postpartum depression can have a detrimental effect on mother-infant bonding and affect the growth and development of the infant. These children may have difficulties with social interactions, cognitive development, and depression. In summary, following the birth of a baby can pose new challenges and often is a stressful time for not only the mother but also other family members. Validation and reassurance from primary care physicians in an empathetic and understanding manner may offer support that many mothers may not have in their close social circle. As the first contact, primary care physicians can identify cues and offer support promptly that will not only improve the mental well-being of mothers but also that of the growing children.___________________________Conclusion: Now we conclude episode number 171, “Postpartum blues, depression, and psychosis.” These conditions may be more common than you think. So, be alert during your prenatal and postpartum visits and start management as needed. Psychotherapy and psychosocial therapy alone may be effective but do not hesitate to start antidepressants or antipsychotics when necessary. Make sure you involve the family and the patient in the decision-making process to implement an effective treatment.This week we thank Hector Arreaza and Vy Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Raza, Sehar K. and Raza, Syed. Postpartum Psychosis. National Library of Medicine. Last updated Jun 26, 2023. https://www.ncbi.nlm.nih.gov/books/NBK544304/Balaram, Kripa and Marwaha, Raman. Postpartum Blues. National Library of Medicine. Last updated Mar 6, 2023. https://www.ncbi.nlm.nih.gov/books/NBK554546/Mughal, Saba, Azhar, Yusra, Siddiqui, Waquar. Postpartum Depression. National Library of Medicine. Last updated Oct 7, 2022. https://www.ncbi.nlm.nih.gov/books/NBK519070/Royalty-free music used for this episode: Good Vibes by Simon Pettersson, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music/.

Episode 170: Schizophrenia: An OverviewFuture Dr. Chng explains the diagnostic criteria and describes how to treat schizophrenia. Dr. Arreaza mentions additional risk factors and social aspects of schizophrenia.  Written by Tiffanny Chng, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Schizophrenia may be an intriguing disease for many, even for health care providers. Schizophrenia is frequently misunderstood and stigmatized. Receiving a diagnosis of schizophrenia can be life-altering and cause significant distress in patients and their families, but it can also impact their work, relationships, and even their communities.Epidemiology of schizophrenia: Schizophrenia has a prevalence of about 1% worldwide, and a prevalence of about 0.6% in the US. Although the distribution between males and females is comparable, males will typically present with their first episode, sometimes known as a “psychotic break” in the early 20’s as opposed to women who may present in their late 20s or early 30s. Despite having a low prevalence, the NIH lists schizophrenia as one of the top 15 leading causes of disability and disease burden in the world. In 2019 the economic burden of schizophrenia in the US was $343 billion. For comparison, in 2019, diabetes had an economic burden of $760 billion in the US, however, the prevalence of diabetes that year was 11.6%, more than 10 times that of schizophrenia. Patients who are diagnosed with schizophrenia are also at increased risk of a multitude of co-occurring medical conditions: alcohol and substance abuse disorders, mood disorders, and metabolic disturbances (diabetes, hyperlipidemia, and obesity, which may be exacerbated with the use of antipsychotics). These patients have a two-to-four-fold increased risk of premature mortality with an estimated potential life loss of ~28.5 years. Of note, 4-10% of patients with schizophrenia die secondary to suicide.Pathogenesis:The exact pathogenesis of schizophrenia is unknown, but we do know that it is a combination of genetic, neurological, and environmental factors. Genetics: Twin studies conducted in mono and dizygotic twins have shown that schizophrenia is highly inheritable (~80%). Although there are no specific genes that directly cause the disease state, genome-wide association studies have shown polygenic additive effects of 108 single nucleotide polymorphisms. This includes genes involved in the dopaminergic and glutamate pathways, which are the basis of antipsychotic medications. Epigenetics: Studies have also shown that epigenetics is a potential factor that plays into the risk of developing schizophrenia. Having a history of obstetric complications, for example, has an almost two-fold increased risk of schizophrenia in the child during early adulthood. Such complications include maternal infections, preterm labor, and fetal hypoxia. Certain infections and pro-inflammatory disease states, such as Celiac and Graves’ disease have also been associated with schizophrenia. The suggested pathophysiology is thought to involve pro-inflammatory cytokines crossing the blood-brain barrier inducing or exacerbating psychosis or cognitive impairment. Trauma: As in many other psychiatric conditions, childhood trauma or severe childhood adversities, especially emotional neglect, have also been shown to increase the risk of schizophrenia later in life.Cannabis and Immigration: So, you mentioned the role of genetics, epigenetics, and inflammation. I’d like to mention the use of cannabis as a risk factor for developing psychosis as well, more specifically the THC component of cannabis. Something to keep in mind during these times when cannabis is being studied in more detail. Also, this is interesting: immigration puts you at risk for schizophrenia, and the risk can be as high as four-fold, depending on the study. Some explanations for this are increased discrimination, stress, and even low vitamin D. Tiffany, how do we diagnose schizophrenia?DSM-5 Diagnostic Criteria: The DSM-5 identifies 5 diagnostic criteria for schizophrenia: Patient must have two or more active phase symptoms for one month or longer: (1) Delusions, (2) Hallucinations (auditory, visual, or tactile) (3) Disorganized speech, (4) Negative symptoms (flat affect, avolition, social withdrawal, anhedonia), or (5) Catatonic behavior (which can be a collection of abnormal physical movements, the lack of movement or resistance to movement, psychomotor agitation). For the first criterion to be met, the patient must have delusions, hallucinations, or disorganized speech as one of their two presenting symptoms. Arreaza: The 1-month duration can be less if the patient is successfully treated.The symptoms experienced by the patient must impair their level of functioning in one or more major areas (professional career, relationships, and self-care). In addition, the disruption must be present most of the time since the onset of symptoms. There must be continuous signs of disturbance for at least 6 months. Within these 6 months, there must be at least 1 month where the patient experiences symptoms mentioned in the first criteria (delusions, hallucinations, disorganized speech, negative symptoms, or catatonic behavior). The disturbance may only be negative symptoms or attenuated positive symptoms (unusual perceptual experiences, odd beliefs, etc.)Mood disorders must be ruled out. This includes bipolar disorder with psychotic features, depressive disorder with psychotic features, and schizoaffective disorder. The behavioral disturbances must not be attributable to any substance use or medical conditions. After the diagnosis of schizophrenia has been made for 1 year or more, specifiers can be added to further categorize the disease state, according to the DSM-V: Acute episode: a period in which all symptomatic criteria are met.Partial remission: a period in which symptomatic criteria are only partially met and symptoms are improved from a previous episode.Full remission: a period in which no symptomatic criteria are met (for a minimum of 6 months).Continuous: symptoms prevalent for the majority of the illness course.Goals of Treatment: Reduce acute symptoms to allow patients to return to their baseline level of functioning. Prevent recurrence and maximize a patient’s quality of life using maintenance therapy.There are 2 components of treatment: Pharmacotherapy and Psychosocial Intervention.Pharmacotherapy.Pharmacotherapy is initiated with second-generation antipsychotics as first-line agents due to their decreased risk of extrapyramidal side effects, compared to our first-generation antipsychotics. Commonly used medications include aripiprazole (Abilify), lurasidone (Latuda), risperidone (Risperdal), and quetiapine (Seroquel). These antipsychotics also have a more favorable side effect profile, showing a lower incidence of seizures, orthostatic hypotension, QT prolongation, weight gain, impaired glucose metabolism, and hyperlipidemia. Of note, younger patients being treated for their first psychotic episode are more likely to experience metabolic side effects while on antipsychotics. Hence, it is important to start at lower doses in these patients and slowly titrate to a therapeutic dose. Antipsychotics are implicated in the development of obesity, and obesity is one of my favorite topics. As a PCP, you need to have close communication with the psychiatrist before you change any doses of any antipsychotics, in my case, I just avoid making changes.Older patients, who are likely on other medications should be started at doses that are ¼ to ½ the adult dose initially to monitor for any potential drug interactions. After therapy initiation, routine monitoring for symptomatic response is done weekly for the first 3 months. Signs of any extrapyramidal symptoms should also be evaluated at each visit. Special care must be taken to patients with risk factors, for example, a metabolic profile should be ordered every 6 to 12 weeks depending on a patient’s comorbidities, and an EKG should be done before and 3 months after therapy initiation to monitor for QT prolongation.QT prolongation is higher with ziprasidone, quetiapine, chlorpromazine, and intravenous (IV) haloperidol. Normal QTc intervals: Before puberty: NORMAL Duration of treatment.APA guidelines state that if no or minimal response (clozapine is recommended. However,  it is important to rule out secondary causes of medication unresponsiveness, such as non-compliance, and co-ingestion of other medications or substances, before initiation of clozapine. For patients who struggle with compliance, long-acting antipsychotic injectables, which are given on a biweekly or monthly basis, may also be a more efficacious option before starting clozapine. Due to the rare but dangerous risk of agranulocytosis, absolute neutrophil levels must be monitored weekly for the first 6 months after treatment initiation of clozapine, then monthly thereafter. Pharmacotherapy duration depends on the patient and the severity of symptoms. For example, the medication can be tapered off if the patient is experiencing their first episode and symptoms are minimally disruptive. However, in most cases, pharmacotherapy is often continued for at least 2-3 years, as maintenance, before tapering or discontinuation. Patients with severe, recurrent symptoms are typically kept on medications indefinitely due to higher risks of relapse. Non-pharmacologic treatment.Psychosocial interventions are focused on family intervention and therapy, social skills training, and cognitive behavioral therapy. Family intervention emphasizes providing support and education to the family/caretakers about the course of the disease, how to recognize symptoms, and understanding the importance of medication compliance. Trained and involved families/caretakers are associated with less frequent relapses, fewer hospital admissions, and less medication nonadherence. Social skills training assists patients in learning basic skills to allow them to carry out everyday activities (taking a bus, paying bills, cooking). It is also used as a method to teach patients how to process emotions they perceive and emotions they experience. This allows patients the ability to build connections with those around them. And finally, cognitive behavioral therapy, CBT, is often used to treat medication-resistant psychosis, to decrease the intensity of delusions or hallucinations. CBT focuses on guiding patients to challenge their delusions or hallucinations, by finding evidence that may negate what they see or hear.In summary, schizophrenia is often seen as a chronic, debilitating condition with a nonlinear course and multifactorial etiology. However, with early diagnosis and a multidisciplinary treatment with consistent, longitudinal follow-up, patients have the potential to reach a functional and independent state in society. Patients who are treated promptly, ideally during their first episode of schizophrenia, have been shown to have a higher rate of remission and an overall better outcome. By understanding the complexity of schizophrenia and recognizing the barriers patients and caretakers may face, primary care physicians can provide the appropriate support, guidance, and resources._________________Conclusion: Now we conclude episode number 170, “Schizophrenia Overview.” Future Dr. Chng explained that genetics, epigenetics, and inflammation are part of the causes of schizophrenia. She explained in detail the diagnostic criteria and how to start treatment. Dr. Arreaza also mentioned that cannabis and immigration can be risk factors for psychosis. Let’s keep in mind the antipsychotic medications, with their side effects and precautions, as part of the treatment, but let’s also remember the family and psychosocial interventions that impact the treatment of this disease. This week we thank Hector Arreaza and Tiffanny Chng. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Psychiatric Association. American Psychiatric Association Practice Guidelines for the Treatment of Psychiatric Disorders. Compendium 2006. American Psychiatric Association; 2006.Patel KR, Cherian J, Gohil K, Atkinson D. Schizophrenia: Overview and Treatment Options. P & T: a peer-reviewed Journal for Formulary Management. 2014;39(9):638-645. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159061/   Correll CU, Brieden A, Janetzky W. Symptomatic, functional and quality of life measures of remission in 194 outpatients with schizophrenia followed naturalistically in a 6-month, non-interventional study of aripiprazole once-monthly. Schizophrenia. 2023;9(1):1-8. doi: https://doi.org/10.1038/s41537-023-00405-5Jenkins TA. Perinatal complications and schizophrenia: involvement of the immune system. Frontiers in Neuroscience. 2013;7. doi: https://doi.org/10.3389/fnins.2013.00110National Institute of Mental Health. Schizophrenia. www.nimh.nih.gov. Published 2019. https://www.nimh.nih.gov/health/statistics/schizophrenia.Kadakia A, Catillon M, Fan Q, et al. The Economic Burden of Schizophrenia in the United States. The Journal of Clinical Psychiatry. 2022;83(6). doi: https://doi.org/10.4088/jcp.22m14458.Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health. Nih.gov. Published June 2016. https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t22/.Royalty-free music used for this episode: Sur La Tabla Beat by audiohero, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music.

Episode 169: Food insecurity and Obesity in Kern CountyFuture Dr. Kim presents the problem of food insecurity in Kern County and how it is linked to obesity and liver disease. She shared several resources available to address food insecurity. Dr. Arreaza reminds us of the importance of improving access to fresh and healthy foods.  Written by Judy Kim, OMS3; Mira Patel, OMS3; and Vy Nguyen, OMS3. Western University of Health Sciences. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: Why did you pick this topic?Judy: While Kern County is known as one of the top-producing agricultural counties in the country, food insecurity is a major health disparity within this county. In order to dissect the problem of food insecurity in Kern County, we must first discuss the demographics and significance of this current topic. Among residents of Kern County, 23.1% are at or below 100% of the federal poverty level (FPL) and 47.7% are low-income (200% of FPL or below), which is higher than that of California.  Arreaza: What is food insecurity? In February 2023, we discussed the definition in Episode 128, but it is important to remember what it is. “Food insecurity is having limited, uncertain, or inconsistent access to the food necessary for a healthy life.” Another interesting fact is that it is estimated that 45% of undocumented immigrants in California are affected by food insecurity, including 64% of undocumented children (Source: 2021 CHIS).Judy: Food insecurity is strongly tied to numerous conditions such as hypertension, coronary artery disease, diabetes, hepatitis, stroke, cancer, asthma, arthritis, chronic obstructive pulmonary disease, and kidney disease. Thus, this problem must be explored and discussed to find ways to improve health outcomes. However, the first steps must focus on bridging gaps in accessing healthy and affordable foods. For example, consumers have consistently noted that reliable transportation is a barrier when even applying for assistance before accessing their benefits. Oftentimes, families experiencing poverty, a large number of residents in Kern County, are part of the migrant community, move frequently, and experience difficulties even completing the necessary paperwork for programs such as the Migrant Childcare Alternative Payment program. Arreaza: It may be off-topic, but I had to search what MCAP is. The Migrant Childcare Alternative Payment (MCAP) Program provides childcare services to migrant farm worker families in Kern and other counties in California, such as Merced and Fresno. MCAP allows parents to work while children are taken care of by licensed childcare centers, licensed family childcare homes, license-exempt (relatives), and in-home providers. I think many families may not be aware of this program. This is a reminder for our residents and students that this is available for your patients. Judy: Going back to food insecurity, when looking at the distribution and locations of large supermarkets in the greater Bakersfield area, such as Albertsons, Smart & Final, and Vallarta, the northwest area has many large stores and without a high density of households in poverty. In contrast, Oildale, the southwest and southeast areas do not have many large markets nearby. Thus, it is also important to examine how and where our patients can access healthy and affordable food.Obesity and Fatty Liver Disease in Kern County.Judy: I would like to describe the relationship between food insecurity with liver disease. The food insecurity that is prevalent in Kern County contributes to the increasing number of overweight and obese populations we see here. Almost 78% of adults in Kern County are considered either overweight or obese. This is concerning because increased rates of obesity are correlated with higher rates of liver disease. As we know, the liver is responsible for breaking down fats, creating new small and medium-chain fatty acids, and transporting fats. With obesity, fat tends to accumulate in the liver since it is unable to properly break down the fat. This leads to steatosis. Short-term fatty liver disease does not have many clinical findings associated with it, but long term if left uncontrolled it can lead to cirrhosis and death. Arreaza: According to a review of the liver transplant list done in 2022, Non-alcoholic steatohepatitis (NASH) is currently the second leading cause of liver transplant overall, and in females, it is the number-one cause. In California, we see about 13.8 deaths per 100,000 persons from liver-related disease, but Kern County has a high 15.9 deaths per 100,000 persons, which exceeded the Healthy People 2020 objective for liver disease deaths of 8.2 per 100,000 persons. Judy: This was found in Kern Medical Community Needs assessments so these deaths could be correlated to NAFLD, NASH, fatty liver, autoimmune hepatitis, etc. but it is still concerning that the number of deaths from liver disease is about 2x the goal of maximum deaths we would want. Arreaza: So, you are linking food insecurity to obesity, and obesity to fatty liver disease, I see the correlation. Tell us about the local resources to address the problem of food insecurity. Local Resources Judy: As patients walk through our doors, we recognize the social determinants for health and quality of life of our patients. Besides providing affirmations and words of encouragement, it’s helpful for the physician and medical staff to offer specific local resources that one can refer to. We collected a list of available resources, please keep in mind that this is not an exhaustive list of the support available in Kern County. Rely on resources around you such as local organizations like Community Action Partnership of Kern (CAPK) and social workers in conjunction with your research to have a comprehensive understanding of what’s available for your patients. Arreaza: The first notable resource you guys found is the Commodity Supplemental Food Program, for our unique population– the elderly. It’s a USDA-sponsored program that provides a 30-lb monthly food box for seniors 60 years and older who also fall below the federal income guidelines. Judy: The Golden Empire Gleaners also offer support to eligible seniors via a program called  Senior Sack, which has established over 20 sites throughout Kern County. Twice a month, each registered  senior will pick up 10-12 items of fresh fruits, vegetables, canned food, bread, and boxed staples at a local site. Upon arrival, they also engage in interactive activities with the staff and learn more about other local services available.Arreaza: Another resource is the Food Bank, provided by several nonprofit organizations such as Community Action Partnership of Kern, Golden Empire Gleaners,  where individuals of any age can come and receive nutritious food every month. Home delivery and emergency food boxes for seniors are also available. Judy: There are also farmers markets such as F Street Farmers Market, which operates year-round every Saturday from 7:45 am to noon. What’s unique about F Street is they offer Market Match which matches program assistance’s benefits such as that of CalFresh and eWIC to the farmers' markets and other farm-directed sites. How it works is when individuals use their benefits, Market Match will match that fund so the person can buy even more fruits and vegetables. For example, if I use $10 of CalFresh benefits at the farmers’ market, I will also receive another $10 for a total of $20 to spend on any fresh produce. F Street Farmers Market will match up to $20 per visit year-round which increases access to fresh fruits and vegetables, as well as provides an incentive for the locals to support family farms and their businesses. To find other farmers' markets that offer other benefits, please visit Farmers Market Finder by Ecology Center or call CAPK for other free food distribution sites. Arreaza: I have to mention this wonderful initiative which I have participated in many times. It is called the bishop’s storehouse, sponsored by The Church of Jesus Christ of Latter-day Saints. It is a place where those in need can go to obtain food and other supplies at the recommendation of their bishop. So, it requires a “ticket” from a bishop, who is the leader of a congregation, to receive goods for free. People of any faith can request this help by going to any church location. So, we mentioned the Commodity Supplemental Food Program, Golden Empire Gleaners, Food Bank, F Street Farmers Market, and the bishop’s storehouse. Judy, thanks for sharing this relevant information. Please give us a conclusion to wrap up this episode.Judy: As primary care doctors we are in a special position to prevent and treat many diseases. By addressing food insecurity, you may have a significant impact on your community. By providing appropriate nutrition, we can fight and prevent many diseases, such as fatty liver disease among others. We should share these resources with patients to improve their access to healthy food.___________________________Conclusion: Now we conclude episode number 169, “Food Insecurity and Obesity in Kern County.” Future Dr. Kim explained that food insecurity is linked to multiple chronic conditions, and she mentioned particularly obesity and fatty liver disease. Food insecurity can be partially addressed by sharing with our patients the resources in our community, and today you heard some of them, but we encourage you to keep looking for many others and share them with your patients. This week we thank Hector Arreaza, Judy Kim, Vy Nguyen, and Mira Patel. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Food Bank - CAPK: Community Action Partnership of Kern. CAPK. (2024, February 27). https://www.capk.org/seniorfood/Kern Food Insecurity Needs Assessment. CAPK. (2023, August). https://feedingkern.org/wp-content/uploads/2023/09/CAPK-Food-Insecurity-Needs-Assessment-Report-revised-with-copyedits-9-11-2023.pdfMarket Match Program Helps Residents Double Their CalFresh Dollars. Department of Public Social Services. (n.d.)https://dpss.lacounty.gov/en/news/2021/05/calfresh-market-match.htmlSenior Sack. Golden Empire Gleaners. (n.d.). https://www.goldenempiregleaners.com/programsSenior food program - CAPK: Community Action Partnership of Kern. CAPK. (2024, February 27). https://www.capk.org/seniorfood/Fabbrini E, Sullivan S, Klein S. Obesity and nonalcoholic fatty liver disease: biochemical, metabolic, and clinical implications. Hepatology. 2010 Feb;51(2):679-89. doi: 10.1002/hep.23280. PMID: 20041406; PMCID: PMC3575093.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575093/Know your numbers. Kern County Public Health. (2024, April 1). https://kernpublichealth.com/knowyournumbers/CAPK feeding Kern - feeding Kern. CAPK Food Assessment Report. (2024, March 15). https://feedingkern.org/Community Health Needs Assessment. (n.d.). https://www.kernmedical.com/documents/Kern-Medical-2019-CHNA-Report-Final.pdfDepartment of Health & Human Services. (2007, November 28). Liver - fatty liver disease. Better Health Channel. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/liver-fatty-liver-disease#Noureddin M, Vipani A, Bresee C, et al. NASH Leading Cause of Liver Transplant in Women: Updated Analysis of Indications For Liver Transplant and Ethnic and Gender Variances. Am J Gastroenterol. 2018;113(11):1649-1659. doi:10.1038/s41395-018-0088-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9083888/The Bishops’ Storehouse, Provident Living, The Church of Jesus Christ of Latter-day Saints, https://providentliving.churchofjesuschrist.org/bishops-storehouse?lang=eng.Royalty-free music used for this episode: Good Vibes by Simon Pettersson, downloaded on July 20, 2023, from  https://www.videvo.net/royalty-free-music

Episode 168: UTI in MalesFuture Dr. Tran gives a summary of UTIs in Males, including epididymitis, orchitis, urethritis, prostatitis, and pyelonephritis. Diagnosis and treatment were briefly described and some differences with female patients were mentioned by Dr. Arreaza.  Written by Di Tran, MS-3, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.WHAT ARE URINARY TRACT INFECTIONS?Urinary Tract Infection (UTI) is an infection of any part of the urinary tract system. It may involve any part of the renal system, the kidneys, the ureters, the bladder, the prostate, and the urethra.  Different from men, a woman may get a UTI more easily due to their anatomical difference. A woman’s urethra is shorter and lies close in proximity to both the vagina and the anus, which allows easy access for bacteria to travel up to the bladder.UTI is further subdivided into two different categories, depending on where the infection takes place within the urinary tract:Lower Tract Infection – cystitis and urethritis when the infection occurs on the bladder and the urethra, respectively.  Common infections are a result of bacteria migrating from the skin (and also from sexual organs) to the urethra and ending up in the bladder.In males, other forms of lower tract infection can result in prostatitis, epididymitis, and orchitis.Upper Tract Infection - aka pyelonephritis, is a more concerning infection that involves the upper parts of the urinary system, in other words, the ureters, and kidneys.AGE DIFFERENCES IN UTI FOR MEN:For men, the incidence of UTI increases with age. Dr. John Brusch reports UTI rarely develops in young males and the prevalence of bacteriuria is 0.1% or less.  Men who are 15-50 years of age often have urethritis due to sexually transmitted infection (STI), mainly by Neisseria gonorrhoeae and Chlamydia trachomatis.  Symptoms include frequency, urgency, and dysuria (most common).Men who are 50 years or older, especially those with prostatic hyperplasia, will have signs and symptoms of incomplete bladder emptying, hesitancy, slow stream, difficulty initiating urination, and dribbling after urinating. Due to the enlargement of the prostate gland, there will be partial blockage of urine flow from the bladder, which in turn, creates a reservoir where bacteria can grow and cause an infection. The most common offending microorganism for this age group is Escherichia coli.Interestingly, while UTIs are rare among men under 60, by the age of 80, both women and men have similar incidence rates. The bladder tends to have a higher residual volume in older males because the prostate grows no matter what, it´s just a part of aging for males. Some may end up with more or less lower urinary tract symptoms, but the prostate is enlarged in general.Other risk factors for UTI in males are men who are not circumcised, urethral strictures, fistulas, hydronephrosis (or dilated ureters overfilled with urine due to failure of drainage to the bladder), and the use of urinary catheters. DIFFERENT TYPES OF UTIs IN MALES:EPIDIDYMITIS:The infection starts from the retrograde ascending route from the prostatic urethra, backing up to the vas deferens, and eventually ending in the epididymis.In men who are younger than 35 years of age, the usual pathogens are C. trachomatis and N. gonorrhoeae (sexually transmitted).In men who are older than 35 years of age, the usual offending agents are Enterobacteriaceae and gram-positive cocci (E. coli as mentioned previously).ORCHITIS:This unique UTI is caused by viral pathogens, such as mumps, coxsackie B, Epstein-Barr (EBV), and varicella (VZV) viruses.  Several studies have shown that patients having orchitis have a history of epididymitis. Fortunately, this infection is uncommon, and it was the main reason to develop the MMR vaccine. It is caused by viruses other than mumps, so you can still have orchitis even if you are vaccinated. Antibiotics are not prescribed for viral orchitis.BACTERIAL CYSTITIS:Having a similar pathophysiology of ascending infection mechanism, male patients in this category often present frequency, urgency, dysuria, nocturia, and suprapubic pain. On a side note, having hematuria is concerning, especially without symptoms, because it’s automatically a red flag that should prompt an immediate evaluation in search of other causes besides infection, such as underlying malignancy. Possible etiologies are calculi, glomerulonephritis, and even schistosomiasis infection that can ultimately result in squamous cell carcinoma of the bladder. Arreaza: Let me share a little anecdote about hematuria. One Sunday when I was a resident I woke up with hematuria. Of course, I immediately went to urgent care, knowing hematuria means trouble in men. I had a urine dipstick test, which was normal. The first thing the nurse practitioner asked me was, “Did you eat any beets?”, and I never eat beets, but that day I had a full bag of beet chips. So, yes, that was the cause of my pseudo-hematuria. Lesson learned: Always ask about beets when you have a patient with painless hematuria with a normal dipstick. PROSTATITIS:This is an infection of the prostate gland. The most common offending agent is E. coli. Acute prostatitis will present with signs of “acute” infection, such as fever, chills, and suprapubic pain. On rectal exam, we will find a prostate that is warm, swollen, boggy, and very tender. Make sure you perform a gentle prostate exam as you may spread bacteria to the blood and cause bacteremia and potentially sepsis. Patients are normally very sick and it is not your typical cystitis, but it is more severe. Chronic Prostatitis can arise from different causes, ranging from retrograde ascending infection, “chronic” exposure to urinary pathogens, and even autoimmune etiologies. The majority of patients often are asymptomatic.   URETHRITIS:This infection is further classified into two groups, gonococcal and non-gonococcal. For gonococcal urethritis, N. gonorrhoeae is the most common pathogen. Agents of non-gonococcal urethritis include C. trachomatis, Ureaplasma, trichomonas, and Herpes Simplex Virus (HSV).  Patients often present symptoms of dysuria, pruritus, and purulent penile discharge.PYELONEPHRITIS:Following a retrograde ascending mechanism, an infection may travel from the bladder and make its way to the kidney, causing damage and inflammation to the renal parenchyma. According to Dr. John Brusch, E. coli is responsible for approximately 25% of cases in males. Pyelonephritis presents with chills, fever, nausea/vomiting, flank pain/costovertebral angle tenderness, and dysuria.  Other findings include pyuria and bacteriuria.  Pyelonephritis is a common cause of sepsis. Diagnosis of UTIs.URINE STUDIES: Urine culture remains the gold standard for diagnosis of UTI. Other studies include suprapubic aspiration, catheterization, midstream clean catch, and Gram stain. Imaging studies are not always needed, but you may order plain films, ultrasonography, CT scans, and MRIs.  It will depend on the severity of your case and your clinical judgment.UTIs in women: In males, we should perform urine culture and susceptibility studies. However, in women, urine studies are not needed all the time, they should be reserved for women with recurrent infection, treatment failure, history of resistant isolates, or atypical presentation. This is done to confirm the diagnosis and guide antibiotic selection.Interestingly, in a recent evidence review, published in the American Family Physician journal, women can self-diagnose their uncomplicated cystitis. All that is needed is having typical symptoms (frequency, urgency, dysuria/burning sensation, nocturia, suprapubic pain), without vaginal discharge. If you have those elements, you have enough information to diagnose, or even the patient can self-diagnose, an uncomplicated UTI without further testing, but in males, you should ALWAYS perform urine studies.TREATMENTS:Men with UTI should ALWAYS receive antibiotics, with urine culture and susceptibility results guiding the antibiotic choice. Laboratory results will help us determine the best treatment plan. UTIs are often treated with a variety of antibiotics.  Dr. Robert Shmerling, of Harvard Medical School, states that most uncomplicated lower tract infections can be eradicated with a week of treatment with antibiotics. Common antibiotics for UTI are fluoroquinolones, trimethoprim-sulfamethoxazole (TMP-SMZ), minocycline, or nitrofurantoin.On another hand, if it’s an upper tract infection or prostatitis, the course of treatment can be extended for longer periods. For those patients who are hemodynamically unstable or have severe upper UTI, hospital admission is required to monitor for complications and IV antibiotics.UTIs in males are less frequent than UTIs in females, except when patients are 80 years and older when the incidence is similar in both sexes. UTIs in males must prompt further evaluation because if left untreated, they can have detrimental effects on your patients’ health. As a take-home point, UTI in males is less common than in females, and it requires urine studies or other studies to identify the etiology and guide treatment. Antibiotics are always used, and you may guide your treatment depending on the results. Imaging is not always needed, but use your clinical judgment to make a more specific diagnosis and detect complications promptly. __________Conclusion: Now we conclude episode number 168, “UTI is Males.” Future Dr. Tran described the different anatomical areas that can be infected in males with UTI. She reminded us that UTIs in males always need to be treated with antibiotics and urine cultures are done to guide treatment. Dr. Arreaza mentioned a few differences in the diagnosis and treatment of UTIs in females. For example, women can self-diagnose an uncomplicated cystitis, and urine studies or antibiotics are not always needed in women. This week we thank Hector Arreaza and Di Tran. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Shmerling, R. H. (2022, December 5). Urinary tract infection in men. Harvard Health Publishing. https://www.health.harvard.edu/a_to_z/urinary-tract-infection-in-men-a-to-z.Brusch, J. L. (2023a, March 27). Urinary tract infection (UTI) in males. emedicine.medscpae.com. https://emedicine.medscape.com/article/231574-overview.Kurotschka PK, Gágyor I, Ebell MH. Acute Uncomplicated UTIs in Adults: Rapid Evidence Review. Am Fam Physician. 2024;109(2):167-174. https://www.aafp.org/pubs/afp/issues/2024/0200/acute-uncomplicated-utis-adults.htmlRoyalty-free music used for this episode: Tropicality by Gushito, downloaded on July 20, 2023, from https://www.videvo.net/royalty-free-music/

Episode 167: Aspirin in PregnancyDr. Marquez explains the use of aspirin during pregnancy to prevent preeclampsia. Dr. Arreaza adds comments and questions and clarifies that aspirin is not used for the treatment of preeclampsia.Written by Verna Marquez, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the topic: Pregnancy is a special time in a woman’s life, and we want to make sure that both the mother and the baby are safe and healthy. 1. What is aspirin? Aspirin is one of the most ancient medications in history, it is known as acetyl-salicylic acid (ASA) and it belongs to the family of non-steroidal anti-inflammatory drugs (NSAID), and it is also an anti-platelet, among other properties that may be unknown. It is widely used for pain, fever, and inflammation, but due to adverse effects during viral illness (i.e. Reye Syndrome), it is used less frequently during viral infections. As we know, aspirin is widely used to treat myocardial infarction and ischemic stroke, and especially for secondary prevention. The use of aspirin for primary prevention of cardiovascular disease has become less popular, but we are going to leave that discussion for another episode because today we will talk about the use of aspirin in pregnancy!2. Why should we use aspirin in pregnancy?Low-dose aspirin in pregnancy is most commonly used to prevent or delay the onset of preeclampsia. Aspirin lowers the risk of preeclampsia by 10% and its consequences (such as growth restriction and preterm birth). Several organizations have agreed on the risk factors we will mention briefly. These organizations are ACOG (American College of Obstetricians and Gynecologists), USPSTF (US Preventive Services Task Force), and SMFM (Society for Maternal-Fetal Medicine).3. Who should we start on aspirin in pregnancy? Aspirin is not for every pregnant patient, for example, a healthy nulliparous or any patient who had an uneventful, full-term delivery previously, is considered low risk and should NOT be started on aspirin because there is no benefit in preventing any condition. Low-dose aspirin is recommended for women who have at least a high-risk factor because the incidence of preeclampsia is about 8% in these patients. The risk factors are:•Previous pregnancy with preeclampsia (especially early onset and with an adverse outcome)•Type 1 or 2 diabetes mellitus.•Chronic hypertension.•Multifetal gestation.•Kidney disease.•Autoimmune disease with potential vascular complications (antiphospholipid syndrome, systemic lupus erythematosus).Your patient only needs 1 high-risk factor to be put on aspirin in pregnancy. 4. What are the moderate risk factors?A patient needs to have more than 1 moderate risk factor to meet the criteria for prenatal aspirin.•Nulliparity.•Obesity (BMI >30).•Family history of preeclampsia in mother or sister.•Age ≥35 years.•Sociodemographic characteristics (Black persons, lower income level [recognizing that these are not biological factors]).•Personal risk factors (for example, previous pregnancy with low birth weight or small for gestational age newborn, previous adverse pregnancy outcome [such as stillbirth], interval >10 years between pregnancies). However, low-dose ASA prophylaxis is not recommended solely for the indication of prior unexplained stillbirth in the absence of risk factor for preeclampsia.•In vitro conception.USPSTF/ACOG may also suggest aspirin in selected patients with only one moderate risk factor, but it would require consultation with a specialist in obstetrics. 5. When should we start aspirin?After 12 weeks of gestation, ideally before 16-20 weeks of gestation. If a patient is more than 16 weeks pregnant, aspirin can be started but most of the benefit has been noted when initiated before 16 weeks because many of the abnormalities that cause preeclampsia are developed early in pregnancy. It is not recommended to start before 11 weeks.It is important to mention also that low-dose aspirin appears to have little or no benefit in patients who already have developed preeclampsia. Starting aspirin in preeclampsia can even cause damage such as bleeding in cases of thrombocytopenia. 6. What is the dose?The dose is between 75 to 162 mg daily. Conveniently, we have an 81 mg presentation in the United States, and it falls within the recommended range. It can be taken in the morning or at night, and adherence of >90% is associated with better prevention.7. When do we stop aspirin?Expert opinion recommends stopping aspirin at the time of delivery. 8. What are the contraindications to ASA use during pregnancy?Absolute contraindications to aspirin: -Patients with a history of ASA allergy (urticaria) or hypersensitivity to other salicylates are at risk of anaphylaxis and should not receive low-dose ASA. -Because of significant cross-sensitivity between ASA and other NSAIDs, low-dose ASA is also contraindicated with known HPS to NSAIDs. -Exposure to low-dose ASA in patients with nasal polyps may result in life-threatening bronchoconstriction and should be avoided.Relative contraindications are history of GI bleed, active peptic ulcer disease, other sources of GI or GU bleeding, and severe hepatic dysfunction.Aspirin is an excellent way to prevent preeclampsia in patients who are at high or moderate risk. Remember to think about the high-risk factors, and if your patient has only 1 positive, then aspirin needs to be started. Mainly, previous preeclampsia, diabetes, hypertension, multifetal gestation, and kidney or autoimmune disease. Look for moderate risk factors and start aspirin if the patient has 2 or more of those risk factors. _________________Conclusion: Now we conclude episode number 167, “Aspirin in Pregnancy.” Dr. Marquez explained that aspirin is started between 12-16 weeks of gestation to prevent preeclampsia in patients with at least 1 high-risk factor or patients with 2 or more moderate-risk factors. Dr. Arreaza also mentioned that aspirin is not for low-risk patients or for patients who already developed preeclampsia. As you know, preeclampsia can result in severe consequences for the fetus and the mother, but by preventing it, we can improve the chances of having a positive outcome in pregnancy. This week we thank Hector Arreaza and Verna Marquez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:August, Phyllis and Arun Jeyabalan, Preeclampsia: Prevention. UpToDate, Last updated Feb 16, 2024. https://www.uptodate.com/contents/preeclampsia-prevention.Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication, September 28, 2021, United States Preventive Services Taskforce https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication.Royalty-free music used for this episode: Tropicality by Gushito, downloaded on July 29, 2023, from https://www.videvo.net/royalty-free-music/. 

Episode 166: Naturopathic Medicine InsightsFuture Dr. Luong talked about what she learned about naturopathic doctors (NDs). She discussed the principles of naturopathic medicine and mentioned some differences in regulations across states in the US. Dr. Arreaza shared his opinion about the pros and cons of naturopathic medicine.  Written by Teresa Luong, MSIV, American University of the Caribbean. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: This may be a controversial topic. The term “natural” in medicine triggers strong reactions among allopathic doctors like me. Today we have a medical student who took up the challenge to talk about Naturopathic Doctors. Teresa:I am providing information based on research and living in Washington state, which is considered one of the birthplaces of modern naturopathic medicine, boasts the highest population of naturopathic doctors and a wide range of practice specialties. It's important to note that my responses are not personal opinions but rather informed insights. There are about 8,500 licensed naturopathic doctors in North America. Naturopathic Doctors may not use the title of physicians in California. What is a Naturopathic Doctor?While it’s true that in California naturopathic doctors are not legally permitted to use the term ”physician” to describe themselves, some still choose to refer to themselves as “naturopathic physicians” colloquially or in their practice branding. So, confusion can arise because naturopathic doctors, while legally not recognized as physicians in California, can function as primary care providers, this overlap in roles can lead to the informal use of terms like ”naturopathic physician.“ However, it’s important to recognize that legally, they are not recognized as physicians in this state. Naturopathic doctors (NDs) are healthcare professionals who embrace a holistic approach to healing, focusing on natural and non-invasive therapies to support the body's inherent ability to heal itself. Naturopathic medicine has its roots in traditional healing practices from around the world, blending ancient wisdom with modern scientific knowledge. The philosophy of naturopathy emphasizes the importance of treating the whole person—mind, body, and spirit—rather than just addressing isolated symptoms or diseases.What is an allopathic approach vs a holistic approach?Allopathic medicine: Allopathic medicine focuses on diagnosing and treating specific symptoms or diseases using pharmaceutical drugs, surgery, and other conventional interventions. Treatment is often targeted at managing symptoms or eradicating pathogens.Holistic medicine: Holistic medicine takes a broader approach, considering the whole person and aiming to address the root causes of illnesses. Treatment may involve a combination of conventional therapies and alternative modalities such as nutrition, herbal medicine, acupuncture, and lifestyle modifications. The focus is on promoting overall health and well-being rather than just treating isolated symptoms.Core Principles Naturopathic Practitioners: The six core principles of naturopathic medicine serve as guiding tenets for both diagnosis and treatment. These principles include: -first, do no harm. -the healing power of nature -identify and treat the root cause -treat the whole person, -the physician as a teacher; -and prevention as the best cure. Treatment modalities: Naturopathic doctors employ a wide range of therapeutic modalities to address the unique needs of each individual, such as:-Clinical nutrition, which focuses on using “food as medicine” to promote healing and prevent disease. -Herbal medicine utilizes the medicinal properties of plants to support various bodily systems and restore balance. -Acupuncture, everybody is familiar with acupuncture. -Other modalities may include hydrotherapy, homeopathy, physical medicine (such as massage and manipulation), and lifestyle counseling.The role of allopathic medications (NSAIDs, antibiotics) and surgical procedures.Naturopathic doctors typically prioritize natural therapies and lifestyle intervention, but may also integrate conventional medicine when necessary. Their views on traditional medications, such as NSAIDs, antibiotics, and surgical procedures vary depending on the individual practitioner and their approach to healthcare. Some may recommend them when appropriate, while others may prefer to explore alternative options first. Ultimately, their goal is often to promote holistic health and well-being. Education and Training: Pre-Medical Requirements: Aspiring naturopathic doctors typically complete undergraduate coursework in pre-medical sciences, including Biology, Chemistry, Physics, and Psychology.Naturopathic Medical Program:Naturopathic doctors must graduate from a four-year accredited naturopathic medical school. The forst two years are basic sciences courses and the last 2 years are clinical courses.After completing their naturopathic medical education, graduates must pass the Naturopathic Physicians Licensing Examinations (NPLEX) to become licensed practitioners. MDs need a residency, and NDs can start working immediately after school in some states, or they can do some additional training.Scope of Practice: The scope of practice for naturopathic doctors varies depending on the regulations in each jurisdiction. In general, NDs are trained to:- Prescribe natural therapies such as nutritional supplements, herbal remedies, and homeopathic medicines.- Prescribe prescription medications, including some, but not limited to, controlled substances.- Provide dietary counseling and lifestyle interventions tailored to individual health needs.- Provide Primary Care, such as, performing physical exams, administering vaccinations, ordering laboratory tests,- Offer acupuncture.- They can use detoxification protocols and intravenous (IV) nutrient therapy into treatment plans.- Utilize mind-body techniques like meditation, mindfulness, and relaxation exercisesIn January 2022, the recognition of naturopathic doctors (NDs) and the extent of their scope of practice vary significantly from state to state within the United States. Here's an overview of states where NDs are recognized and their scope of practice:Licensed States: In these states, naturopathic doctors are licensed to practice independently and have a broad scope of practice, including diagnosis, treatment, and prescription of medications and natural remedies within their scope. Some states may have specific restrictions or additional requirements.-California: NDs are licensed and regulated by the California Naturopathic Medicine Committee. They have a comprehensive scope of practice, including the prescription of certain medications.-Washington: NDs are licensed and regulated by the Washington State Department of Health. They have a limited formulary for prescription medications.Unlicensed States (for example, Georgia and Virginia): In states where naturopathic medicine is not regulated, NDs have to work as healthcare consultants or working alongside other licensed healthcare providers, like MDs. The scope of practice in these states may be more limited, and NDs may not have the authority to diagnose, treat, or prescribe medications independently.Pros:Naturopathic doctors utilize natural and holistic therapies, which may have fewer side effects compared to conventional medications. These therapies can complement conventional treatments, especially if they are collaborating with an MD.If Naturopathic doctors work collaboratively, it can offer complementary care options to patients, which can provide patients with treatment modalities and perspectives beyond conventional medicine. This can be particularly beneficial for patients who are a bit apprehensive to traditional medicine for whatever reason.Naturopathic medicine emphasizes preventive care and strategies to promote health and prevent disease. So they try to catch underlying imbalances and risk factors early, and see patients multiple times a week, which can help patients reduce their risk of developing chronic illnesses and improve their overall quality of life. By seeing a patient this frequently, it promotes stronger doctor-patient relationships and improves patient satisfaction.Cons:Lack of Regulation and Standardization: Naturopathic medicine is not regulated to the same extent as conventional medicine, and there may be variability in the education, training, and qualifications of naturopathic doctors. This lack of regulation and standardization can raise concerns about the quality and safety of naturopathic care.Limited Scientific Evidence: Some naturopathic treatments  lack rigorous scientific evidence supporting their efficacy and safety. Without robust clinical research, it can be challenging to assess the effectiveness of certain naturopathic interventions and differentiate between evidence-based practices and unproven therapies.Potential for Harmful Practices: In some cases, naturopathic doctors may recommend treatments or interventions that have the potential to be harmful, particularly if they lack scientific support or are based on unfounded beliefs. Patients may be at risk of receiving ineffective or unsafe treatments without proper oversight and regulation.Delayed Access to Conventional Care: So if a patient relies solely on naturopathic care, it may delay access to conventional medical treatments that are necessary for managing serious or life-threatening conditionsCost and Insurance Coverage: Naturopathic services may not be covered by health insurance plans, or coverage may be limited compared to conventional medical services. This lack of insurance coverage can make naturopathic care inaccessible to some patients, particularly those with limited financial resources.This information is provided to increase your knowledge on this topic, it is not intended to convince you to go against or support naturopathic medicine. Our goal is to inform you and you can draw your own conclusions about it. It is important to educate ourselves on this topic because naturopathic doctors are rising in California and we may encounter them in our future practices. ________________________________Conclusion: Now we conclude episode number 166, “Naturopathic Medicine Insights.” Future Dr. Luong explained that naturopathic doctors receive training in naturopathic medical schools and receive a degree before they sit for a board exam. Many NDs may be working in outpatient primary care or even in hospital care. Dr. Arreaza shared his opinion about the pros and cons of having naturopathic medicine available for patients.This week we thank Hector Arreaza and Teresa Luong. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! Links: American Association of Naturopathic Physicians:aanp.org. Complementary, Alternative, or Integrative Health: What’s In a Name? NIH National Center for Complementary and Integrative Health, https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name. Accessed March 21, 2024. Bastyr University:bastyr.eduNational University of Natural Medicine (NUNM):nunm.eduFleming SA, Gutknecht NC. Naturopathy and the primary care practice. Prim Care. 2010;37(1):119-136. doi:10.1016/j.pop.2009.09.002. https://pubmed.ncbi.nlm.nih.gov/20189002/Atwood KC 4th. Naturopathy: a critical appraisal. MedGenMed. 2003;5(4):39. Published 2003 Dec 30. https://pubmed.ncbi.nlm.nih.gov/14745386/Public Notification: Artri King contains hidden drug ingredients, U.S. Food & Drug Administration (FDA), April 20, 2022. https://www.fda.gov/drugs/medication-health-fraud/public-notification-artri-king-contains-hidden-drug-ingredientsRoyalty-free music used for this episode: My Dinner with the Diablo by Tropicalia, downloaded on July 20, 2023 from  https://www.videvo.net/. 

Episode 165: Early-Onset Sepsis Part 2Dr. Lovedip Kooner explains how to use the Kaiser Permanente early-onset sepsis calculator and explains other useful tools to assist in the diagnosis of EOS. Dr. Arreaza adds comments about the usefulness of this calculatorWritten by Lovedip Kooner, MD. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: As a recap, Early-onset sepsis is diagnosed within 72 hours (or within 7 days, according to some experts) after birth. We talked about GBS as the main culprit of EOS. 28% of EOS by GBS are babies born Using the Kaiser Permanente (KP) neonatal EOS calculator.Lovedip: It is a multivariate risk assessment tool that guides us in the management of neonatal early-onset sepsis. The Kaiser Permanente (KP) neonatal EOS calculator combines 2 predictive models. One model is based on risk factors known at birth and the other model is based on the newborn clinical condition during the early hours after birth. The risk factors are: gestational age, highest maternal antepartum temperature, maternal GBS status, duration of rupture of membranes, and antibiotics (type and duration). If that sounds familiar, it is. It’s mostly the same information used in the categorical risk assessment, except substituting maternal highest antepartum temperature for chorioamnionitis diagnosis. This information is input into the calculator and two values are obtained. The first value is the EOS risk at birth, the second value is the EOS risk after the clinical exam. The clinical exam is broken down into well-appearing, equivocal, and clinical illness.The well-appearing baby in general is described as alert and consolable, moving all extremities, good skin color no bruising, except possibly acrocyanosis, hungry and when put on mom’s breast will attempt to suckle, normal vital signs, good reflexes like Moro and grasp, tends to have flexed limbs, especially arms, regards faces  but no tracking. In a previous episode, we mentioned that hypoglycemia is not a good indicator of EOS caused by GBS. Let’s talk about the criteria for a well-appearing baby in the Kaiser Permanente tool.Well-appearing for the purposes of the KP calculator means no persistent physiologic abnormalities. Equivocal means: “Tachy, Tachy, Temp, Resp”Persistent physiologic abnormality > 4 hrsTwo or more physiologic abnormalities lasting for > 2 hrsNote: abnormality can be intermittent.An ill newborn, in general, is described as having abnormal vital signs, either hyper or hypothermia, tachycardia, bradycardia or arrhythmia, flaccid, doesn’t regard faces, no or muted reflexes and poor suck, mottled color, cyanosis or bruising, petechiae, retractions, nasal flair or poor nasal breathing (with choanal atresia, pinks up only when crying), gasping respirations,  poor bowel sounds, possibly distended OR scaphoid (with atresias will have scaphoid abdomen and with anomalies like TEF depending on type, emesis or difficulty breathing when fed)  obvious congenital anomalies, etc.Clinical Illness in the Kaiser Permanentetool is defined as:Persistent need for Nasal CPAP / High flow nasal cannula / mechanical ventilation (outside of the delivery room)Hemodynamic instability requiring vasoactive medicationsNeonatal encephalopathy/Perinatal depression: Seizure, Apgar Score @ 5 minutes Need for supplemental O2 > 2 hours to maintain oxygen saturations > 90% (outside of the delivery room)After all that information is entered into the Kaiser Permanente calculator, the options for management are clinical monitoring, laboratory evaluation, or antibiotic administration. Example: -Incidence: 0.5/1,000 live births -Gestational age: 36 6/7 weeks-Highest maternal antepartum temperature: 102 F-ROM: 5 hours-Maternal GBS: Positive-Intrapartum antibiotics: Broad spectrum 3 hours prior to birth-RESULT: EOS risk at birth 2.34.Recommendations based on physical exam:1. Well-appearing baby, risk 0.96, RECOMMENDATIONS: No culture, no antibiotics, vitals every 4 hours for 24 hours.2. Equivocal, risk 11.61, RECOMMENDATIONS: Start empiric antibiotics and vitals per NICU.3. Clinical Illness, risk 47.46, RECOMMENDATIONS: Start empiric antibiotics and vitals per NICU.The Kaiser Permanente neonatal early-onset sepsis calculator was analyzed in a meta-analysis, as published in the American Family Physician in 2021. Six high-quality, non-randomized controlled trials were evaluated, including more than 170,000 neonates. The calculator was compared to the standard approach recommended by the CDC guidelines. The analysis showed there was a statistically significant reduction in antibiotic use, a reduction in the number of laboratory tests, and a reduction in NICU admission in neonates who were managed following the sepsis calculator compared with the standard approach. There was no difference in readmission rates to NICU and no difference in culture-positive sepsis between neonates treated using the sepsis calculator and those treated with the standard approach. In summary, I recommend using the Kaiser Permanente calculator as part of your evaluation. BTW, I received no money from KP. It is important to know that depending on resources and institutional policies, your management may change.Use of CBC and CRP.CBC interpretation in neonates: Remember that CBC in newborns needs to be evaluated following the normal parameters for neonates. For example, WBC up to 30,000 per mm3, and hemoglobin up to 19.9 gm/dL can be normal in neonates. Serial white blood cell counts and immature–to–total neutrophil ratio (I/T ratio) generally greater than or equal to 0.2 by some experts is considered positive for sepsis. Complete blood cell counts taken 12-24 hours after birth are associated with increased sensitivity and negative predictive value compared to a sample taken 1-7 hours after birth. C-reactive protein (CRP) is also often used and it rises within 6 hours of infection and peaks at 24 hours. Two normal CRP levels, one taken between 8-24 hours of age and the second 24 hours later, have an over 99% negative predictive value. Single values of CRP or procalcitonin obtained after birth to assess the risk of EOS are neither sensitive nor specific to guide EOS care decisions.Procalcitonin: Procalcitonin may be difficult to interpret within the first 3 days after birth due to elevations caused by noninfectious etiologies and the physiologic rise after birth. It is important to note that neither single values of CRP nor procalcitonin after birth should be used to guide the management plan of infants undergoing evaluation for EOS>.Extreme values in CBC: Extreme values (total WBC count 0.3; ANC 0.5] in the other) were associated with the highest likelihood ratios but very low sensitivities.Cultures/lab tests: Culture results are used to confirm suspected sepsis. You must not wait for the result to start treatment with empiric, broad-spectrum antibiotics in newborns suspected to have EOS. Treatment:The recommended empirical antibiotic regimen for most at-risk infants for Early-Onset Sepsis involves combining ampicillin and gentamicin. In the case of critically ill term infants, the empirical use of additional broad-spectrum agents may be warranted until culture results are available and an appropriate treatment plan can be determined.In areas with E. coli highly resistant to ampicillin, carbapenem should be considered. When blood cultures are sterile, antibiotic therapy should be discontinued by 36 to 48 hours of incubation unless there is clear evidence of site-specific infection.Why not treat everyone with antibiotics?Unneeded antibiotics can cause changes in the GI flora (needed for vitamin K ) and disturb the whole gut colonization with healthy bacterial flora, this can have an impact on the newborn’s kidney if dosage is not corrected (Harriet Lane Handbook gives neonatal doses) because GFR is lower in neonates, and side effects are always possible. In the neonatal nursery, the emergence of resistant bacteria is always a worry.Antibiotic resistance is one of the most feared threats to humanity. In retrospective studies primarily focused on term infants, researchers have associated early antibiotic administration with elevated risks of various health issues in later childhood, including wheezing, asthma, food allergy, inflammatory bowel disease, and childhood obesity.Take home points:(1) Understand how to assess a newborn infant’s risk of EOS.(2) Understand how to determine which steps should be taken at particular levels of risk, including the timely administration of empirical, broad-spectrum antibiotic therapy.(3) Understand how to decide when to discontinue empirical antibiotic therapy. (4) Consistently normal values of CRP and procalcitonin over the first 48 hours of age are associated with the absence of EOS, but serial abnormal values alone should not be used to decide whether to administer antibiotics in the absence of culture-confirmed infection.____________________Conclusion: Now we conclude episode number 165, “Early Onset Sepsis Part 2.” Dr. Kooner explained the elements of the Kaiser Permanente Early Onset Sepsis calculator available online for free. Dr. Arreaza provided insights on the usefulness of this tool. Some other markers, such as CBC, CRP, and procalcitonin were also explained. This week we thank Hector Arreaza, Lovedip Kooner, and Katherine Schlaerth. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Neonatal Early-Onset Sepsis Calculator by Kaiser Permanente, available at:  https://neonatalsepsiscalculator.kaiserpermanente.org/.Espinosa K, Brown SR. Neonatal Early-Onset Sepsis Calculator. Am Fam Physician. 2021;104(6):636-637.https://www.aafp.org/pubs/afp/issues/2021/1200/p636.html.Puopolo KM, Benitz WE, Zaoutis TE; COMMITTEE ON FETUS AND NEWBORN; COMMITTEE ON INFECTIOUS DISEASES. Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. 2018 Dec;142(6):e20182894. doi: 10.1542/peds.2018-2894. PMID: 30455342. https://pubmed.ncbi.nlm.nih.gov/30455342/.Briggs-Steinberg C, Roth P. Early-Onset Sepsis in Newborns. Pediatr Rev. 2023 Jan 1;44(1):14-22. doi: 10.1542/pir.2020-001164. PMID: 36587021. https://pubmed.ncbi.nlm.nih.gov/36587021/.Flannery DD, Puopolo KM. Neonatal Early-Onset Sepsis. Neoreviews. 2022 Nov 1;23(11):756-770. doi: 10.1542/neo.23-10-e756. PMID: 36316253. https://pubmed.ncbi.nlm.nih.gov/36316253/.Polin RA; Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Pediatrics. 2012 May;129(5):1006-15. doi: 10.1542/peds.2012-0541. Epub 2012 Apr 30. PMID: 22547779. https://pubmed.ncbi.nlm.nih.gov/22547779/.Royalty-free music used for this episode: Good Vibes by SImon Peterrson, downloaded on July 20, 2023 from  https://www.videvo.net/

Episode 164: More Than Just A HeadacheDr. Song presents a case of a subacute headache that required an extensive workup and multiple visits to the hospital and clinic to get a diagnosis. Dr. Arreaza added comments about common causes of subacute headaches.    Written by Zheng (David) Song, MD. Editing and comments by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction to the episode: We are happy to announce the class of 2027 of the Rio Bravo / Clinica Sierra Vista Family Medicine Residency Program. Our new group will be (in alphabetical order): Ahamed El Azzih Mohamad, Basiru Omisore, Kenechukwu Nweke, Mariano Rubio, Nariman Almnini, Patrick De Luna, Sheila Toro, and Syed Hasan. We welcome all of you. We hope you can enjoy 3 enriching and fulfilling years. During this episode, you will hear a conversation between Dr. Arreaza and Dr. Song. Some elements of the case have been modified or omitted to protect the patient’s confidentiality. 1. Introduction to the case: Headache. A 40-year-old male with no significant PMH presents to the ED in a local hospital due to over a month history of headaches. Per the patient, headaches usually start from the bilateral temporal side as a tingling sensation, and it goes to the frontal part of the head and then moves up to the top of the head. 8 out of 10 severities were the worst. Pt reports sometimes hypersensitivity to outdoor sunlight but not indoor light. OTC ibuprofen was helpful for the headache, but the headache always came back after a few hours. The patient states that if he gets up too quickly, he feels slightly dizzy sometimes, but it is only for a short period of time. There was only one episode of double vision lasting a few seconds about 2 weeks ago but otherwise, the patient denies any other neurological symptom. He does not know the cause of the headache and denies any similar history of headaches in the past. The patient denies any vomiting, chest pain, shortness of breath, cough, abdominal pain, or joint pain. The patient further denies any recent traveling or sick contact. He does not take any chronic medication. The patient denies any previous surgical history. He does not smoke, drink, or use illicit drugs. What are your differential diagnoses at this moment? Primary care: Tension headache, migraines, chronic sinusitis, and more.2. Continuation of the case: Fever and immigrant.Upon further inquiries, the patient endorses frequent “low-grade fever” but he did not check his temperature. He denies any significant fatigue, night sweats, or weight loss. He migrated from Bolivia to the U.S. 12 years ago and has been working as a farm worker in California for the past 10 years. He is married. His wife and daughter are at home in Bolivia. He is currently living with friends. He is not sexually active at this moment and denies having any sexual partners. Differential diagnoses at this moment?  Tension headache, migraine, infections, autoimmune disease, neurocysticercosis. 3. Continuation of the case: Antibiotics and eosinophilia. As we kept asking for more information, the patient remembered he visited a clinic about four months ago for a dry cough and was told he had bronchitis and was given antibiotics and the cough got better after that. He went to another local hospital ED one month after that because the cough came back, now with occasional phlegm and at that time he also noticed two “bumps” on his face but nothing significant. After a CXR at the ED, the patient was diagnosed with community-acquired pneumonia and sent home with cough medication and another course of antibiotics. His cough improved after the second round of antibiotics. We later found on the medical record that the CXR showed “mild coarse perihilar interstitial infiltrates of unknown acuity”. His blood works at the ED showed WBC 15.2, with lymphocyte 21.2%, monocyte 10.1%, neutrophil 61.7%, eosinophil 5.9% (normally 1-4%), normal kidney, liver functions, and electrolytes, and prescribed with benzonatate 100mg TID and doxycycline 100mg bid for 10 days. He went to the same ED one month before he saw us for headache and fever (we reviewed his EMR, and temp was 99.8F at the ED). After normal CBC, CMP and chest x-ray. The patient was diagnosed with a viral illness and discharged home with ibuprofen 400mg q8h.Due to the ongoing symptoms of headache and fever, the patient went back to the same clinic he went to four months ago for a dry cough and requested a complete physical and blood work. The patient was told he had a viral condition and was sent home with oseltamivir (Tamiflu®) for five days. However, the provider did order some blood work for him. Differential diagnoses at this moment?  Patients with subacute meningitis typically have an unrelenting headache, stiff neck, low-grade fever, and lethargy for days to several weeks before they present for evaluation. Cranial nerve abnormalities and night sweats may be present. Common causative organisms include M. tuberculosis, C. neoformans, H. capsulatum, C. immitis, and T. pallidum. At his physical exam visit, the patient actually asked the provider specifically to check him for coccidiomycosis because of his job as a farm worker and he heard from his friends that the infection rate is pretty high in the Central Valley of California. His serum cocci serology panel showed positive IGG and IGM with CF titer of 1:128. His HIV, syphilis, HCV, HBV are all negative. The patient was told by that clinic to come to ED due to his history of headache, fever, and very high serum coccidiomycosis titer.  The senior and resident intern were on the night shift that night and we were contacted by the ED provider at around 9:30 pm for this patient. When reviewing his ED record, his vitals were totally normal at the ED, the preliminary ED non-contrast head CT showed no acute intracranial abnormality. A lumbar puncture was performed by the ED provider, which showed WBCs (505 - 71%N, 20%L, 7%M), RBC (1), glucose (19), and protein (200). CSF: High Leukocytes, low glucose, and high protein.On the physical exam, the patient was pleasant and cooperative, he was A&O x 4, he had a normal examination except for two brown healing small nodules on his forehead and left cheek and slight neck stiffness. At that point, we knew the patient most likely had fungal meningitis by cocci except for the predominant WBC in his CSF fluid was neutrophil not the more typical picture of lymphocyte dominant. And because of his very benign presentation and subacute history, we were not 100% sure if we had a strong reason to admit this patient. We thought this patient could be managed as an outpatient with oral fluconazole and referred to infectious disease and neurology. 4. Continuation of case: Admission to the hospital.Looking back, one thing that was overlooked while checking this patient in the ED was the LP opening pressure. Later, the open pressure was reported as 340mm H2O (very high). The good thing was, after speaking to the ED attending and our attending, the patient was admitted to the hospital and started on oral fluconazole.  Three hours after the admission, a rapid response was called on him. While the floor nurses were doing their check-in physical examination, the patient had a 5-minute episode of seizure-like activity which included bilateral tonic arm/hand movements, eye deviation to the left, LOC unresponsive to sternal rub, and the patient desaturated to 77%. He eventually regained consciousness after the seizure and pulse oximetry increased to 100% on room air. The patient was started on Keppra and seen by a neurologist the following day. His 12-hour EEG was normal, but his head MRI showed “diffuse thickening and nodularity of the basal meninges are seen demonstrating enhancement, suggesting chronic meningitis, possibly related to cocci. Other etiologies including sarcoidosis and TB meningitis and/or infiltration by metastatic process/lymphoma are not excluded. The ventricles are slightly prominent in size”. MRI of the cervical, thoracic, and lumbar spines also showed extensive diffuse leptomeningeal thickening, extensive meningitis, and nodular dural thickening. Also, his chest x-ray showed “some heterogeneity and remodeling of the distal half of the left clavicle. Metabolic bone disease, infectious etiology and/old trauma considered”. This could also be due to disseminated cocci infection. The infectious disease doctor saw this patient and recommended continuing with fluconazole, serial LPs until opening pressure is less than 250 mmH2O and neurosurgery consultation for possible VP shunt placement. The neurologist recommended the patient continue with Keppra indefinitely in the context of structural brain damage secondary to cocci meningitis.Take home points: Suspect cocci meningitis in patients with subacute headache associated with respiratory symptoms, new skin lesions, photophobia, neck stiffness, nausea, vomiting, eosinophilia, erythema nodosum (painful nodules on the anterior aspect of legs). Other symptoms to look for include arthralgias, particularly of the ankles, knees, and wrists.____________________Brief summary of coccidiomycosis. Etiology Coccidioidomycosis, commonly known as Valley fever, is caused by dimorphic soil-dwelling fungi of the genus Coccidioides (C. immitis and C. posadasii). They are indistinguishable in clinical presentation and routine laboratory test results.1, 2, 3, 5Epidemiology In the United States, endemic areas include the southern portion of the San Joaquin Valley of California and the south-central region of Arizona. However, infection may be acquired in other areas of the southwestern United States, including the southern coastal counties in California, southern Nevada, southwestern Utah, southern New Mexico, and western Texas (including the Rio Grande Valley). There are also cases in eastern Washington state and in northeastern Utah. Outside the United States, coccidioidomycosis is endemic to northern Mexico as well as to localized regions of Central and South America.1, 2Overall, the incidence within the United States increased substantially over the 1998-2019, most of that increase occurred in south-central Arizona and in the southern San Joaquin Valley of California. From 1998 to2019, reported cases in California increased from 719 to 9004.1, 6The risk of infection is increased by direct exposure to soil harboring Coccidioides. Past outbreaks have occurred in military trainees, archaeologists, construction or agricultural workers, people exposed to earthquakes or dust storms. However, in endemic areas, many cases of Coccidioides infection occur without obvious soil or dust exposure and are not associated with outbreaks. Change in population, climate change, urbanization and construction activities, and increased awareness and reporting, are possible contributing factors.1, 2, 5 Pathology In the soil, Coccidioides organisms exist as filamentous molds. Small structures called arthroconidia from the hyphae may become airborne for extended periods. Arthroconidia are usually 3-5 μm—small enough to evade bronchial tree mucosal mechanical defenses and reach deep into the lungs.1, 3Once inhaled by a susceptible host into the lung, the arthroconidia develop into spherules (theparasitic existence in a host), which are unique to Coccidioides. Endospores from ruptured spherules can themselves develop into spherules, thus propagating infection locally.1, 3, 5Although rare cases of solid organ donor-derived or fomite transmitted infections have been reported, coccidioidomycosis does not occur in person-to-person or zoonotic contagion, and transplacental infection in humans has never been documented.2, 5Cellular immunity plays a crucial role in the host’s control of coccidioidomycosis. Among individuals with decreased cellular immunity, Coccidioides may spread locally or hematogenously after an initial symptomatic or asymptomatic pulmonary infection to extrathoracic organs.1, 3, 7Clinical manifestationThe majority of infected individuals (about 60%) are completely asymptomatic. Symptomatic persons (40% of cases) have symptoms that are related principally to pulmonary infection, including cough, dyspnea, and pleuritic chest pain. Some patients may also experience fever, headache (common finding in early-stage infection and does not represent meningitis), fatigue, night sweats, rash, myalgia.1, 2, 3, 5In most patients, primary pulmonary coccidioidomycosis usually resolves in weeks without sequelae and lifelong immunity to reinfection. However, some patients may develop chronic pulmonary complications, such as nodules or pulmonary cavities, or chronic fibrocavitary pneumonia. Some individuals with intense environmental exposure or profoundly suppressed cellular immunity (e.g., in patients with AIDS) may develop a primary pneumonia with diffuse reticulonodular pulmonary process in association with dyspnea and fever.1, 3, 5Fewer than 1% of infected individuals develop extrathoracic disseminated coccidioidal infection. Common sites for dissemination include joints and bones, skin and soft tissues, and meninges. One site or multiple anatomic foci may be affected. 1, 2, 3, 7It is estimated that coccidioidal meningitis, the most lethal complication of coccidioidomycosis, affects only 0.1% of all exposed individuals. Patients with coccidioidal meningitis usually present with a persistent headache (rather than a self-limited headache in some patients with primary pulmonary infection), with nausea and vomiting, and sometimes vision change. Some may also develop altered mental status and confusion. Meningismus such as nuchal rigidity, if present, is not severe.Hydrocephalus and cerebral infarction may develop in some cases. Papilledema is more commonly observed in pediatric patients.1, 3, 4, 5, 7When meningitis develops, most patients may not have any respiratory symptoms nor radiographic manifestation of pulmonary infection. However, a large number of these individuals also present with other extrathoracic lesions.7DiagnosisAlthough early diagnosis carries obvious benefits for patients and the health care systems as a whole (e.g., decreases patient anxiety, reduces the cost of expensive and invasive tests, removes the temptation for empirical antibacterial or antiviral treatments, and allows for early detection of complications), considerable diagnostic delays up to several weeks to months are common in both endemic areas and non-endemic areas.3, 7 Most symptomatic persons with coccidioidal infection present with primarily pulmonary symptoms and are often misdiagnosed as community-acquired bacterial pneumonia and treated with antibiotics. In endemic areas like south-central Arizona, previous studies found up to 29% of community-acquired pneumonia is caused by coccidioidomycosis. Healthcare providers thus should maintain a high clinical suspicion for coccidioidomycosis when evaluating persons with pneumonia who live in or have traveled to endemic areas recently. Elevated peripheral-blood eosinophilia of over 5%, hilar or mediastinal adenopathy on chest radiography, marked fatigue, and failure to improve with antibiotic therapy should prompt suspicion and testing for infection with coccidioidomycosis in endemic areas.1, 3, 5Serological testing plays an important role in establishing a diagnosis of coccidioidomycosis. Enzyme immunoassay (EIA) to detect IgM and IgG antibodies is highly sensitive and therefore commonly used as the screening tool. Immunodiffusion is more specific but less sensitive than enzyme immunoassay. It is used to confirm the diagnosis of positive EIA test results. Complement fixing (CF) test, which indirectly detects the presence of coccidioidal antibodies by testing the consumption of serum complement, are expressed as titers. Serial measurements of titers are of not only diagnostic but also prognostic value.1, 2, 3, 5Other methods, including culture, microscopic, or polymerase chain reaction (PCR) exam on tissue or respiratory specimens, are limited by their availability, sample obtaining and handling, or lack of sufficient evaluation.1, 2, 3, 5Cerebrospinal fluid (CSF) examination in coccidioidal meningitis usually demonstrates lymphocyte dominated elevation of leukocytes, although polymorphonuclear leukocyte dominance can also be seen in the early stage of the infection. Profound hypoglycorrhachia and elevated protein levels in CSF examination are also very common in coccidioidal meningitis.1, 7Although isolating Coccidioides from CSF or other CNS specimens are diagnostic for coccidioidal meningitis, in practice, diagnoses are often made based on the combination of clinical presentation, CSF examination that suggesting fungal infection, and positive Coccidioides antibodies found in CSF.7Imaging, especially enhanced magnetic resonance imaging (MRI), can help in diagnosing coccidioidal meningitis. Basilar leptomeningeal enhancement is a more common finding even though hydrocephalus, cerebral infarction, and vertebral artery aneurysm can also be seen.7TreatmentMost patients with focal primary pulmonary coccidioidomycosis do not require antifungal therapy. According to 2016 Infectious Diseases Society of America (IDSA) Clinical Practice Guideline, antifungal therapy should be considered in patients with concurrent immunosuppression that adversely affect cellular immunity (e.g., organ transplant patients, AIDS in HIV-infected patients, and patients receiving anti–tumor necrosis factor therapy) and those with significantly debilitating illness, extensive pulmonary involvement, with concurrent diabetes, pregnant women, or who are otherwise frail because of age or comorbidities. Some experts would also include African or Filipino ancestry as indications for treatment. Conversely, humoral immunity comprise splenectomy, hypocomplementemia, or neutrophil dysfunction syndromes are not major risk factors for this disease.1, 2, 3, 4, 5Triazole antifungals (fluconazole or itraconazole) are currently considered as the first-line medications used to treat most cases of coccidioidomycosis. Amphotericin B is reserved for only the most severe cases of dissemination and patients with coccidioidal meningitis in whom triazole antifungal therapy has failed. It is also the choice of therapy for coccidioidomycosis in pregnant women during the first trimester because of the possible teratogenic effect of high-dose triazole therapy during this period of time.1, 3, 4, 5Treating coccidioidal meningitis (CM) poses a special challenge because untreated meningitis is nearly always fatal. Lifelong therapy is recommended for CM because the majority 80% patients with CM experience relapse when therapy is stopped despite initial response to antifungal treatment. Shunting of CSF is required in cases of meningitis complicated by hydrocephalus.1, 3, 4, 5, 7Prevention Avoidance of direct contact with contaminated soil in endemic areas (e.g., respirator use by construction workers) may reduce disease risk, although clear evidence of its benefit is lacking.1, 5Some special population groups may benefit from prophylactic use of antifungals, such as those about to undergo allogeneic solid-organ transplantation or patients with a history of active coccidioidomycosis or a positive coccidioidal serology in whom therapy with tumor necrosis factor α antagonists is being initiated. The administration of prophylactic antifungals is not recommended for HIV-1-infected patients even if they live in an endemic region.1, 5Conclusion: Now we conclude episode number 164, “More than just a headache.” Dr. Song explained that a headache with an indolent course, accompanied by subacute respiratory symptoms, nausea, vomiting, photophobia, neck stiffness, and skin lesions can be secondary to Valley Fever. The Central Valley of California, as well as other areas with dry climate, are endemic and we need to keep this disease in our differential diagnosis.This week we thank Hector Arreaza and Zheng (David) Song. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Roos KL, Tyler KL. Acute Meningitis. McGraw Hill Medical. Published 2023. Accessed August 18, 2023. https://accessmedicine.mhmedical.com/content.aspx?bookid=2129§ionid=192020493Information for Healthcare Professionals. Published 2023. Accessed August 18, 2023. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/health-professionals.html#printValley Fever (Coccidioidomycosis) a Training Manual for Primary Care Professionals. Accessed August 18, 2023. https://vfce.arizona.edu/sites/default/files/valleyfever_training_manual_2019_mar_final-references_different_colors.pdfAmpel NM. Coccidioidomycosis. Idsociety.org. Published July 27, 2016. Accessed August 18, 2023. https://www.idsociety.org/practice-guideline/coccidioidomycosis/Herrick KR, Trondle ME, Febles TT. Coccidioidomycosis (Valley Fever) in Primary Care. American Family Physician. 2020;101(4):221-228. Accessed August 18, 2023. https://www.aafp.org/pubs/afp/issues/2020/0215/p221.htmlValley Fever Statistics. Published 2023. Accessed August 18, 2023. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/statistics.htmlUpToDate. Uptodate.com. Published 2023. Accessed August 18, 2023. https://www.uptodate.com/contents/coccidioidal-meningitis?search=7%20Coccidioidal%20meningitis&source=search_result&selectedTitle=1~10&usage_type=default&display_rank=1Royalty-free music used for this episode: Tropicality by Gushito, downloaded on July 20, 2023, from  https://www.videvo.net/

Episode 163: Vascular Dementia      Future Dr. Ruby explains gives a definition of vascular dementia and concisely explains the pathophysiology and presentation of this disease. Dr. Arreaza reminds us of the importance of treating diabetes to prevent dementia.  Written by Carmen Ruby, MSIV, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is vascular dementia?Vascular dementia is a condition that arises due to damage to blood vessels that reduce or block blood flow to the brain. A stroke can block an artery and result in various symptoms, such as changes in memory, thinking, or movement. Other conditions like high blood pressure or diabetes can also damage blood vessels and lead to memory or thinking problems over time.Vascular dementia (VaD) is a type of dementia that slowly worsens cognitive functions and is thought to be caused by vascular disease within the brain. Patients with VaD often exhibit symptoms similar to Alzheimer's disease (AD) patients. However, the changes in the brain are not due to Alzheimer’s disease pathology (amyloid plaques and neurofibrillary tangles) but due to a chronic reduction in blood flow to the brain, eventually leading to dementia. Alzheimer’s disease pathophysiology is very complex, and studies have shown that patients with AD can experience simultaneously several vascular issues that can affect cognitive function. For example, patients with AD may experience mini-strokes and have a reduction of the flow of oxygen and nutrients to the brain tissue. So, AD can be worsened by vascular factors as well, but the vascular factors are not the main problem in AD.Clinically, patients with VaD can appear very similar to those with AD, which makes it difficult to distinguish between the two diseases. Nevertheless, some clinical symptoms and brain imaging findings suggest that vascular disease is contributing to, if not entirely explaining, a patient's cognitive impairment.Epidemiology.In the US, VaD is the 2nd most common type of dementia (15-20% of cases). Prevalence increases with age (∼ 1–4% in patients ≥ 65 years.) People affected by vascular dementia typically start experiencing symptoms after age 65, although the risk is significantly higher for people in their 80s and 90s.EtiologyVaD may occur as a result of prolonged and severe cerebral ischemia of any etiology, primarily:Large artery occlusion (usually cortical ischemia) *Acute*Lacunar stroke (small vessel occlusion resulting in subcortical ischemia) *Acute/Subacute**Chronic* subcortical ischemiaRisk factors:Advanced ageHistory of strokeUnderlying conditions associated with cardiovascular disease:Chronic hypertensionDiabetesDyslipidemiaObesitySmokingClinical Features:Symptoms depend on the location of ischemic events and, therefore, vary widely amongst individuals, but a progressive impairment of daily life is common. Because of the diverse clinical picture, the term "vascular cognitive impairment" is gaining popularity over Vascular Dementia.Dementia due to small vessel disease:Symptoms tend to progress gradually or in a stepwise fashion and comparatively slower than in multi-infarct dementia.Generally associated with signs of subcortical pathology:Dementia due to large vessel disease Usually, sudden onsetMulti-infarct dementia: typically, stepwise deterioration Generally associated with signs of cortical pathology:Early symptomsReduced executive functioningLoss of visuospatial abilitiesConfusion ApathyMotor disorders (e.g., gait disturbance, urinary incontinence)Later symptomsImpaired memoryFurther cognitive decline: loss of judgment, disorientationMood disorders (e.g., euphoria, depression)Behavioral changes (e.g., aggressiveness)Advanced stages: further motor deterioration: dysphagia, dysarthriaDementia due to large vessel disease Usually, sudden onsetMulti-infarct dementia: typically, stepwise deterioration Generally associated with signs of cortical pathology:Cognitive impairment in combination with asymmetric or focal deficits (e.g., unilateral visual field defects, hemiparesis, Babinski reflex present)Overall, the symptoms vary depending on which areas of the brain are affected.Management and TreatmentThere is hope when it comes to managing the symptoms of vascular dementia. Although there is no cure for the condition, there are medications available that can help make life easier for those living with it. Additionally, there are drugs commonly used to treat memory issues in Alzheimer's disease that may be effective for individuals with vascular dementia. Sometimes, people with vascular dementia may experience mood changes, such as depression or irritability. These changes can be managed with medications used for depression or anxiety.Vascular risk modification: If your patient is experiencing cognitive impairment and has clinical or radiologic evidence of cerebrovascular pathology, getting screened for vascular risk factors, especially hypertension, is essential. Treatment can help prevent dementia, but it may not be as effective in reversing it. Statins are given after a stroke regardless of lipid levels.Antithrombotic therapy: For patients with vascular dementia who have had a clinical ischemic stroke or transient ischemic attack, they must receive the appropriate antithrombotic therapy based on the specific stroke subtype to help prevent any future ischemic strokes.When considering antiplatelet therapy for patients with vascular dementia who have not had a clinical ischemic stroke or TIA, it is important to make an individualized decision. For instance, we may prescribe aspirin at a dosage of 50-100 mg daily for patients with an infarction seen on brain imaging but not for those with only white matter lesions.Cholinesterase inhibitor therapy: It is recommended to start cholinesterase inhibitor therapy, such as donepezil or galantamine, for patients with vascular dementia who have a gradual cognitive decline that is not a direct result of a stroke. The evidence suggests that this treatment may offer a small cognitive benefit, but the clinical significance is unclear. Experts do not recommend cholinesterase inhibitors for patients with dementia diagnosed after a stroke if there is no gradual cognitive decline.Antipsychotics: We can briefly mention antipsychotics. They may be used but we have to remember they may increase mortality in the elderly, and the patient and family must be aware of this risk. Some examples are risperidone, quetiapine, and olanzapine, use them cautiously. Let’s talk beyond medications, what other treatments can we offer? Non-pharmacologic options: In addition to medications, there are various ways to help a person with vascular dementia. Research has shown that physical exercise, sleep hygiene, and maintaining a healthy weight can not only enhance brain health but also reduce the risk of heart problems, stroke, and other diseases that affect blood vessels. Patients must be encouraged to eat a balanced diet, get enough sleep,limit alcohol intake, and encouraged to quit smoking, as these are other crucial ways to promote good brain health and reduce the risk of heart disease. Additionally, comorbid conditions such as diabetes, high blood pressure, or high cholesterol, must be treated, because they affect brain function and quality of life overall.It is essential to understand that emotional outbursts and personality changes can be caused by underlying brain disease and are not always intentional responses or reactions. When behavior problems overwhelm an individual, their family members, or friends, it is critical to seek support. Patient and caregiver support groups are helpful, offering a space to vent, grieve, and gain practical advice from others experiencing similar challenges. Exploring other sources of support, such as adult day programs, can also benefit caregivers and individuals affected by vascular dementia. Conclusion: Now we conclude episode number 163, “Vascular dementia basics.” Future Dr. Ruby explained that vascular dementia is mainly caused by an impaired circulation of blood and oxygen to certain areas in the brain. This can be a result of large or small vessel disease. Dr. Arreaza reminded us of the importance of treating diabetes as a way to prevent dementia. This week we thank Hector Arreaza and Carmen Ruby. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Smith, MD EE, Wright, MD, MS CB. Treatment of Vascular Cognitive Impairment and Dementia. Wilterdink, MD JL, ed. UpToDate. Published online May 24, 2022. Accessed February 27, 2024. https://www.uptodate.comVascular Dementia. Memory and Aging Center. Published 2020. https://memory.ucsf.edu/dementia/vascular-dementiaVascular dementia. AMBOSS. Published online June 29, 2023. Accessed February 28, 2024. https://www.amboss.com/usWhat Happens to the Brain in Alzheimer's Disease? National Institute on Aging, https://www.nia.nih.gov/health/alzheimers-causes-and-risk-factors/what-happens-brain-alzheimers-disease. Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/. 

Episode 162: Early-Onset Sepsis      Dr. Kooner explains how to diagnose early-onset sepsis by using clinical evaluation and clinical tools. Dr. Schlaerths describes the signs and symptoms of sepsis in neonates, and Dr. Arreaza adds comments about GBS bacteriuria.  Written by Lovedip Kooner, MD, editing Hector Arreaza, MD, and comments by Katherine Schlaerth, MD. Rio Bravo Family Medicine Residency Program.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Neonatal sepsis is defined as pathogenic bacterial growth from blood or cerebral spinal fluid culture within the first 28 days of life. Neonatal sepsis can be divided into two categories: early-onset sepsis (EOS) and late-onset.  EOS is neonatal sepsis within 72 hours or 7 days after birth, depending on the specialist. How common is early-onset sepsis (EOS)?According to the CDC, the infant mortality rate rose for the first time in 20 years in the USA. In the U.S., the incidence of EOS is 0.5 in 1,000 live births and carries a mortality rate of about 3%. What causes EOS?Most infections are due to ascending lower vaginal tract flora. Other causes include intra-amniotic infections and maternal hematogenous spread of systemic infections. Group B streptococcus (S. agalactiae) accounts for about 1/3 of the infectious organisms, followed by E. coli which accounts for about 1/4, and Viridans streptococci account for about 1/5 of infections. Cases of E. coli are seen more often with prolonged rupture of membranes and intrapartum antibiotic exposure. Other notable infections are Listeria monocytogenes, coagulase-negative staphylococci (CoNS), herpes simplex virus, and enteroviruses. The role of GBS.Approximately 30% of women have vaginal and rectal GBS colonization and 50% will transmit it to the newborn. Without maternal antibiotic treatment, 1-2% of those infants will develop EOS. The American College of Obstetricians and Gynecologists (ACOG) recommends universal culture-based screening for GBS at 36-37 weeks and 6 days regardless of mode of delivery. GBS bacteriuria: Treat it (symptomatic and asymptomatic) if >105 CFU/mL. Do not treat it in asymptomatic patients if GBS Intrapartum antibiotic prophylaxis for GBS.The indications for intrapartum antibiotic prophylaxis for GBS EOS are: previous neonate with invasive GBS disease, positive GBS culture unless C-section is performed before rupture of membranes, GBS bacteriuria at any point during the current pregnancy.If GBS status is unknown: At least one of the following criteria must be met: prematurity, rupture of membranes >18 hours, intrapartum fever, or GBS positive in previous pregnancy.Nucleic acid amplification test: NAAT in pregnancy is not recommended to determine colonization status. However, if NAAT is obtained in the intrapartum period, give IAP if positive. But, you must also give IAP if negative + mentioned risk factors (18h, Maternal fever >100.4F)What is considered adequate intrapartum antibiotic prophylaxis? Penicillin and ampicillin are the recommended antibiotics for prophylaxis. Cefazolin can be given if there is a penicillin-allergy with a low risk for anaphylaxis. Clindamycin and vancomycin are reserved for cases of maternal penicillin allergy. Specifically, clindamycin can be used only if GBS is known to be sensitive to clindamycin. Vancomycin must be used if GBS is resistant to clindamycin. Do not use erythromycin. You will Administered at least 4 hours before delivery.IAP is believed to reduce neonatal GBS disease by: (1) temporarily reducing maternal vaginal GBS colonization; (2) preventing colonization of the fetus or newborn's surfaces and mucous membranes; and (3) achieving antibiotic levels in the newborn's bloodstream sufficient to surpass the minimum inhibitory concentration (MIC) for eliminating group B streptococci.Diagnosis of EOS:Clinical presentation: Tachycardia, tachypnea, temperature instability, supplemental oxygen requirement, and lethargy. Hypoglycemia should not be considered a sign of EOS.Diagnosing early-onset sepsis is achieved through blood or cerebrospinal fluid (CSF) cultures. Not effective methods for diagnosing EOS include laboratory tests, such as a complete blood cell count or C-reactive protein (CRP), as well as surface cultures, gastric aspirate analysis, or urine culture.Most infants will generally show signs of EOS GBS infection within the initial 24 hours of birth, with approximately 85% exhibiting symptoms during this timeframe.Waiting for cultures and/or signs can delay lifesaving treatment.Management:According to the American Academy of Pediatrics (AAP), the management of term and late-term infants is undertaken via the clinical condition assessment, the categorical risk factor assessment, and the multivariate risk assessment. As a part of the 2015 AAP guidelines, the Categorical Risk Factor Assessment is more of an algorithmic approach based on the presence or absence of specific risk factor threshold values such as:Ill-appearing infant. Mother diagnosed with chorioamnionitis.Mother GBS positive with inadequate intrapartum prophylaxis.ROM >18 hours.Birth before 37 weeks of gestation.Antibiotics are not always needed, and they can even cause damage. Information taken from the American Academy of Pediatrics, “Management of Neonates Born at ≥35 0/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial Sepsis,” published on December 1, 2018:(1) Any newborn infant who is ill-appearing or (2) when the mother has a clinical diagnosis of chorioamnionitis -> laboratory testing must be ordered, and empirical antibiotic therapy should be started.(3) A mother who is colonized with GBS and who received inadequate intrapartum antibiotic prophylaxis, with a duration of ROM being >18 hours or birth before 37 weeks’ gestation -> laboratory testing should be ordered.(4) A mother who is colonized with GBS who received inadequate IAP but with no additional risk factors -> observation in the hospital for ≥48 hours.______________________________Conclusion: Now we conclude episode number 162, “Early-onset Sepsis Introduction.” Dr Kooner explained the role of GBS in the pathophysiology of EOS, Dr. Schlaerth discussed the importance of clinical evaluation and Dr. Arreaza explained that GBS screening in the third trimester is not needed when there is a GBS positive urine culture early in pregnancy. Don’t miss part 2 of this discussion. By the way, we do not recommend using feces to prevent or treat sepsis, we just shared anecdotal information to end with a funny note.This week we thank Hector Arreaza, Lovedip Kooner, and Katherine Schlaerth. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Neonatal Early-Onset Sepsis Calculator by Kaiser Permanente, available at: https://neonatalsepsiscalculator.kaiserpermanente.org/.Espinosa K, Brown SR. Neonatal Early-Onset Sepsis Calculator. Am Fam Physician. 2021;104(6):636-637.https://www.aafp.org/pubs/afp/issues/2021/1200/p636.html.Puopolo KM, Benitz WE, Zaoutis TE; COMMITTEE ON FETUS AND NEWBORN; COMMITTEE ON INFECTIOUS DISEASES. Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics. 2018 Dec;142(6):e20182894. doi: 10.1542/peds.2018-2894. PMID: 30455342. https://pubmed.ncbi.nlm.nih.gov/30455342/.Briggs-Steinberg C, Roth P. Early-Onset Sepsis in Newborns. Pediatr Rev. 2023 Jan 1;44(1):14-22. doi: 10.1542/pir.2020-001164. PMID: 36587021. https://pubmed.ncbi.nlm.nih.gov/36587021/.Flannery DD, Puopolo KM. Neonatal Early-Onset Sepsis. Neoreviews. 2022 Nov 1;23(11):756-770. doi: 10.1542/neo.23-10-e756. PMID: 36316253. https://pubmed.ncbi.nlm.nih.gov/36316253/.Polin RA; Committee on Fetus and Newborn. Management of neonates with suspected or proven early-onset bacterial sepsis. Pediatrics. 2012 May;129(5):1006-15. doi: 10.1542/peds.2012-0541. Epub 2012 Apr 30. PMID: 22547779. https://pubmed.ncbi.nlm.nih.gov/22547779/.Royalty-free music used for this episode: Good Vibes_Adventure Time by Simon Pettersson, downloaded on July 20, 2023, from https://www.videvo.net/  

Episode 161: Depression FundamentalsFuture doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end.  Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Per the language of Mental Health, depression can be defined as a mood, a symptom, a syndrome of associated disorders, or a specific mental disorder. As a state of mood, depression is associated with feelings of sadness, despair, emptiness, discouragement, and hopelessness. The sense of having no feelings or appearing tearful can also be a form of depressed mood. A depressed mood also can be a part of a collection of symptoms that explain a syndrome. Depression as a mental disorder can encompass depressive syndromes. Per the American Psychiatric Association DSM-5-TR, depressive disorders commonly include sad, empty, irritable mood, accompanied by changes in one’s functional capacity. They can be classified by severity and recurrence, and associated with hypomania, mania, or psychosis. Depressive disorders include major depressive disorder (including major depressive episodes), persistent depressive disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, depressive disorder due to medical condition, other specified depressive disorder, and unspecified depressive disorder.Today, we will cover unipolar depressive disorder, also known as major depressive disorder. MDD.Major depressive disorder is a mood disorder primarily characterized by at least one major depressive episode without manic or hypomanic episodes. Depressive episode is a period of at least 2 weeks of depressed mood or anhedonia in nearly all activities for most of the day nearly every day, with four or more associated symptoms in the same 2 weeks. We will discuss specific symptoms for diagnosis further on. Epidemiology of depression.Nationally or regionally representative surveys in 21 countries estimate that the 12-month prevalence of major depressive disorder across all countries is 5 percent. Furthermore, the prevalence of major depressive disorder plus persistent depressive disorder in developed countries (United States and Europe) is approximately 18 percent. Multiple studies consistently indicate that in the general population of the United States, the average age of onset for unipolar major depression and for persistent depressive disorder (dysthymia) is approximately 30 years old. During 2020, approximately ⅕ US adults have reported receiving a diagnosis by a healthcare provider, with the highest prevalence found among young adults age (18-24 year age… generation Z). Within the US there was considerable geographic variation in the prevalence of depression, with the highest state and county estimates of depression observed along the Appalachian and southern Mississippi Valley regions. Why do we care about depression?Because depression is associated with impaired life quality. It can impair a patient’s social, physical, and psychological functioning. Also, depression is associated with mortality. A study done by UPenn Family Practice and Community Medicine in 2005 showed that among older, primary-care patients over a 2-year follow-up interval, depression contributed as much to mortality as did myocardial infarction or diabetes. A prospective study from 2005-2017 that followed 186 patients for up to 38 years further showed that patients with major depressive disorder had 27 times higher incidence rate of suicide than the general population. (1, 2). Also, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. It is estimated that 45% of patients who died by suicide saw their primary care physician in the month before their death. Only 20% saw a mental health professional a month before their death. (3)Suicidality in depression.It seems that primary care physicians often do not ask about suicidal symptoms in depressive patients. A 2007 study by Mitchell Feldman at the University of California San Francisco showed that 152 family physicians and internists who participated in a standardized patient with antidepressants, suicide was explored in only 36% of the encounters. (4)Physicians, including primary care physicians, should ask patients with depression about suicidality with questions such as: Do you wish you were dead? In the past few weeks, have you been thinking about killing yourself? Do you have a plan to kill yourself? Have you ever tried to kill yourself? (5) Screening for depression.The USPSTF recommends screening for depression in all adults: 18 years old and over regardless of risk factors. Some factors increase the risk of positive screening, such as temperament (negative affectivity/neuroticism), general medical illness, and family history. First-degree family members of people with MDD have a 2-4 times higher risk of MDD than the general population. Furthermore, social history can increase risk as well: sexual abuse, racism, and other forms of discrimination.It is important to highlight the risk in women because they may also be at risk related to specific reproductive life stages (premenstrual period, postpartum, perimenopause). The USPSTF includes pregnant individuals and patients in the postpartum period to be screened for depression. Screening tools. The US Preventive Services Task Force recommends depression screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years (grade B). Similarly, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) has also recommended annual screening for depression in children aged 12 and older. (6) Some tools used for screening in this age group are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI). For the general adult population, it is recommended that all patients not currently receiving treatment for depression be screened using the Patient Health Questionnaire-2 (PHQ-2) (7)PHQ 2 is a survey scored 0-6. The survey asks two questions: Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things.Feeling down, depressed, or hopeless.Answers should be given in a numerical rating. 0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day. A score ≥ 3 is considered positive, and a follow-up full clinical assessment is recommended. The PHQ-2 has a sensitivity of 91% and a specificity of 67% when compared to a semi-structured interview. Keep in mind that the PHQ-2 may be slightly less sensitive to older individuals. Individuals who screen positive with PHQ-2 should have additional screening with the PHQ-9, which is a nine-item, self or clinician-administered, brief questionnaire that is specific to depression. (8) Its content maps directly to the DSM-5 criteria for major depression. (9)The PHQ-9 is a set of 9 questions. The answers are scored similarly to PHQ-2, with a numerical scoring between 0 and 3. (0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day). Dr. Arreaza, you will be my patient today, are you ready? It’s important that you think about the last 2 weeks.Over the last 2 weeks, how often have you been bothered by any of the following problems?Little interest or pleasure in doing things. [Dr. Arreaza answers, “sometimes”. Jane asks, “is it several days or nearly every day?”. Dr. Arreaza answers, “nearly every day” 3]Feeling down, depressed or hopeless [Dr. Arreaza: every day 3]Trouble falling or staying asleep, or sleeping too much [Dr. Arreaza: not at all 0]Feeling tired or having little energy [Dr. Arreaza: not at all 0]Poor appetite or overeating [Dr. Arreaza: every day 3]Feeling bad about yourself- or that you are a failure or have let yourself or your family down [Dr. Arreaza: several days 1]Trouble concentrating on things, such as reading the newspaper or watching television [Dr. Arreaza: Several days 2]Moving or speaking so slowly that other people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual. [Dr. Arreaza: Not at all 0]Thoughts that you would be better off dead, or of hurting yourself [Not at all 0]Jane: Your score is 12.Maddy: Regarding severity, a total score of 1-4 suggests minimal depression. 5-9 suggests mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression. PHQ-9 with patients’ scores over 10 had a specificity of 88% and sensitivity of 88% for MDD. (10)But if there are at least 4 non-zero items, including question #1 or #2, consider a depressive disorder and add up the scores. If there are at least 5 non-zero items including questions #1 or #2, consider major depressive disorder specifically. The questionnaire is the starting point for a conversation about depression.A couple of things to note: 1. Physicians should make sure to verify patient responses given the questionnaire can be self-administered. Diagnosis also requires impairment in the patient’s job, social, or other important areas of functioning. 2. Diagnosis requires a ruling-out of normal bereavement, histories of manic episodes, depressive episodes better explained by schizoaffective disorder, any superimposed schizophrenia, a physical disorder, medication, or other biological cause of depressive symptoms.Once a patient is newly diagnosed and/or started on treatment, a regular interval administration (e.g. 2 weeks or at every appointment) of PHQ-9 is recommended. The PHQ-9 has good reliability, validity, and high adaptability for MDD patients in psychiatric hospitals for screening and evaluation of depression severity. (12) Other than PHQ-9, there is also Geriatric Depression Scale-15 for older patients with mini mental status exam (MMSE) that scored over 10. (13)For postpartum depression, the preferred screening tool is the Edinburgh postnatal depression scale[Click here (stanford.edu)].Non-pharmacologic and pharmacologic treatment.Now that we have diagnosed the patient, we have to start management. Patients can consider non-pharmacologic treatment such as lifestyle modifications. This can include sleep hygiene, reduction in drug use, increased social support, regular aerobic exercise, finding time for relaxation, and improved nutrition. Furthermore, based on severity, patients can start psychotherapy alone or psychotherapy + pharmacotherapy. Admission is required for pts with complex/severe depression or suicidality. There should be an assessment of efficacy at 6 weeks.There is a warning about patients aged 18-24 who are at increased risk of suicide when taking SSRI within the first couple weeks of treatment. Mediations: SSRI, SNRI, tricyclic antidepressants, MAOIs, and Atypical antidepressants: including trazodone, mirtazapine (Remeron), bupropion (Wellbutrin SR). More research is being done on psychedelic drugs such as ketamine and psilocybin as possible treatments. There are therapies such as ECT available too.Potential Harm of Tx: Potential harms of pharmacotherapy: -SNRI:  initial increases in anxiety, insomnia, and restlessness, and possible sexual dysfunction and headaches as well. Compared with the SSRI class, the SNRI class tends to induce more nausea, insomnia, dry mouth, and in rare cases hypertension.-Tricyclic: Cause of numerous side effects, very infrequently prescribed unless the patient is not responding to other forms of treatment. Side effects that are included are: dry mouth. slight blurring of vision, constipation, problems passing urine, drowsiness, dizziness,  weight gain, excessive sweating (especially at night). Avoid TCAs in elderly patients.-MAOIS: MAO-IS can cause side effects too, including dizziness or lightheadedness, dry mouth, nausea, diarrhea or constipation, drowsiness, and insomnia. Furthermore, other less common side effects can include involuntary muscle jerks, hypotension, reduced sexual desire/ ability to orgasm, weight gain, difficulty starting urine flow, muscle cramps, and paresthesia.Remember to screen your patients. In case you establish a diagnosis, discuss treatments, including non-pharmacologic and pharmacologic options. Warn your patients about side effects and the timing to see the benefits of the medication, usually after 6 weeks. __________________Conclusion: Now we conclude episode number 161, “Depression Fundamentals.” Future doctors Park and Tena discussed depression and its risk factors, screening, and treatment. They went through the PHQ2 and PHQ9 as screening tools, as well as commonly used treatments and their side effects, such as SSRIs. Dr. Arreaza also highlighted the importance of asking about suicidality in your depressed patients, there is a lot of room for improvement in that aspect. This week we thank Hector Arreaza, Madeline Tena, and Jane Park. Audio editing by Adrianne Silva.Talk_OutroEven without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Angst F, Stassen HH, Clayton PJ, Angst J. Mortality of patients with mood disorders: follow-up over 34-38 years. J Affect Disord. 2002;68(2-3):167-181. doi:10.1016/s0165-0327(01)00377-9. https://pubmed.ncbi.nlm.nih.gov/12063145/Miron O, Yu KH, Wilf-Miron R, Kohane IS. Suicide Rates Among Adolescents and Young Adults in the United States, 2000-2017. JAMA. 2019;321(23):2362-2364. doi:10.1001/jama.2019.5054. https://pubmed.ncbi.nlm.nih.gov/31211337/ Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5(5):412-418. doi:10.1370/afm.719. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2000302/.Brief Suicide Safety Assessment,National Institute of Mental Health (NIMH), July 11, 2020. https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/adult-outpatient/bssa_outpatient_adult_asq_nimh_toolkit.pdfBeck A, LeBlanc JC, Morissette K, et al. Screening for depression in children and adolescents: a protocol for a systematic review update. Syst Rev. 2021;10(1):24. Published 2021 Jan 12. doi:10.1186/s13643-020-01568-3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802305/Williams, John; Nieuwsma, Jason. Screening for depression in adults, UpToDate, updated on November 30, 2023. https://www.uptodate.com/contents/screening-for-depression-in-adults.Instrument: Patient Health Questionnaire-9 (PHQ-9), National Institute on Drug Abuse, https://cde.nida.nih.gov/instrument/f226b1a0-897c-de2a-e040-bb89ad4338b9.Lowe B, et al. Monitoring depression-treatment outcomes with the Patient Health Questionnaire-9 (PHQ-9). Med Care, 42, 1194-1201, 2004.Sun, Y., Fu, Z., Bo, Q. et al.The reliability and validity of PHQ-9 in patients with major depressive disorder in psychiatric hospital. BMC Psychiatry20, 474 (2020). https://doi.org/10.1186/s12888-020-02885-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/Conradsson M, Rosendahl E, Littbrand H, Gustafson Y, Olofsson B, Lövheim H. Usefulness of the Geriatric Depression Scale 15-item version among very old people with and without cognitive impairment. Aging Ment Health. 2013;17(5):638-645. doi:10.1080/13607863.2012.758231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701937/.Royalty-free music used for this episode: Old Mexican Sunset by Videvo, downloaded on Nov 06, 2023 from https://www.videvo.net

Episode 160: Artificial Intelligence in Primary Care.      Future Dr. Manophinives explains the present and future of AI in diagnosing and treating diseases.    Written by Rosalynn Manophinives, MS-IV, American University of the Caribbean. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today, we embark on an intriguing journey at the crossroads of technology and healthcare: The Future of Healthcare in Artificial Intelligence (AI) and Machine Learning (ML). Let’s start by establishing the groundwork for AI and ML. Artificial Intelligence involves machines mirroring cognitive functions like learning and problem-solving, while machine learning empowers machines to learn from data and refine their capabilities over time. In healthcare, these technologies aim to elevate diagnostic precision and treatment effectiveness which are pivotal aspects in primary care medicine.Accurate diagnosis is the cornerstone of effective patient care in all forms of medicine because an accurate diagnosis guides treatment decisions and influences patient outcomes. This is why the integration of AI and ML holds immense promise in this field.Section 1: AI in Diagnostic Assistance (4 mins)Let’s explore how AI utilizes algorithms to analyze extensive datasets, enhancing diagnostic accuracy significantly.AI serves as a revolutionary force in analyzing a large amount of data, particularly in medical imaging. Imagine AI algorithms as super brains, employing machine learning to decipher intricate details from X-rays, MRIs, and CT scans. Notably, studies have demonstrated their precision matching and even surpassing that of human experts. For instance, research published in the Journal of the American Medical Association revealed AI algorithms outperforming radiologists in detecting conditions like breast cancer.AI's skills extend beyond images. It digs into genetic information, medical history, and treatment outcomes, acting as a detective to spot patterns, predict responses, and customize interventions. Studies support this, showcasing AI models outperforming dermatologists in diagnosing skin cancer from images. Will AI replace doctors?The beauty of AI is that it does not replace doctors but acts as a super investigator in your healthcare corner, expediting diagnoses, and refining treatments. So, AI isn’t merely accelerating processes; it’s enhancing healthcare outcomes, making diagnoses quicker, and treatments more precise, and minimizing errors. The future appears very promising with AI leading the way to more precise and tailored healthcare.Section 2: Case Studies in Diagnosis (4 mins):Help in research: Let’s delve into real-life examples of AI in action, further amplifying diagnostic accuracy. In a research study, Rajkomar and collaborators crafted an AI algorithm predicting patient deterioration within hours, leveraging electronic health record data. This tool allowed for proactive care, identifying potential issues before they escalated. Taking it up a notch, Aliper and collaborators compared AI to human researchers, resulting in AI outsmarting human brains in designing drugs targeting age-related diseases. These experiments underscore AI's potential in diagnostics, from catching issues early to designing groundbreaking drugs.AI here enhances doctors' capabilities and acts as an additional set of eyes, boosting their superpowers, spotting nuances, and proposing game-changing solutions in medicine.Section 3: AI in Risk Prediction (4 mins):Let’s shift our focus to AI's role in predicting risks and prognosis, particularly in conditions like COPD.AI employs sophisticated algorithms to analyze patient data comprehensively, including demographics, hospital visits, diagnoses, prescribed medications, and lab results. In COPD, AI not only predicts mortality but also anticipates hospital readmissions for respiratory issues or flare-ups. By scrutinizing various markers, AI resembles Sherlock Holmes, unraveling clues within data.And AI doesn’t stop there, AI integrates risk predictions into medical practices, which fosters personalized care tailored to individual risk factors. A study led by Choi and their team analyzed retrospective patient data and they were able to identify individuals at risk of undiagnosed COPD, emphasizing the significance of catching potential issues early, finding those who might slip through the cracks otherwise, which is huge! Section 4: AI in Treatment Planning (4 mins):Let’s now explore how AI is revolutionizing treatment planning within medicine.AI, equipped with machine learning algorithms, tailors treatments by analyzing patient-specific data and medical history. In cancer, for example, AI analyzes biopsy images and quantifies biomarkers, facilitating personalized treatments. Beyond cancer, AI extends its reach to cell therapies, predicting their effectiveness through genomic information and drug responses.And here's the techie part: AI employs various smart algorithms like Convolutional Neural Networks (CNN) and Recurrent Neural Networks (RNN) to provide personalized treatment recommendations. It’s like having personalized treatment recommendations by experts that fit you like a glove, catering to individual needs. Section 5: Fuzzy Cognitive Maps and Reduction of Medical Errors (4 mins):Lastly, let me tell you about the impact of AI-driven treatment planning, specifically in reducing medical errors. Imagine this—medical decisions? They're tough. Sifting through tons of data, inaccessible medical records, physicians' lack of experience, and loads of conflicting info, makes the decision often not crystal clear. This is where a high percentage of medical errors occur, which is where Fuzzy Cognitive Maps (FCMs) come in.  FCMs are like a super-smart tool that mimics human reasoning, tackling the messiness of medical data with grace.FCMs are all about modeling complex systems, by combining fuzzy logic and neural networks, just like our brain does—connecting the dots between concepts and their cause-and-effect relationships. From patient records to test results, they make sense of it all.And FCM is not just theory—FCMs are the real deal and they're not the newbies in town; they've been around for a while, evolving from their early days. They've proven their worth in various medical areas too – in radiotherapy planning, diagnosing language impairments, and even in grading tumors!So, in a nutshell, FCMs are useful tools for medical decision support by taking on the complexities of diagnosing and treatment planning.Closing:In conclusion, the integration of Artificial Intelligence and Machine Learning in healthcare is a thrilling frontier, offering invaluable tools to enhance diagnostic accuracy and patient outcomes. As we evolve, responsible use of these advances is paramount, ensuring they optimize rather than replace the indispensable human touch in healthcare.Thank you for joining me in exploring the future of healthcare in AI and Machine Learning. I trust this discussion has sparked curiosity and appreciation for the transformative potential of technology in healthcare. -----------------------------------Conclusion: Now we conclude episode number 160, “Artificial Intelligence in Primary Care.” This is a new and somewhat unknown field of medicine that is rapidly evolving these days. Future Dr. Manophinives explained that AI and ML can be a useful tool in the diagnosis of diseases by, for example, interpreting images accurately. AI also can help develop plans of care by interpreting large amounts of complex data and predicting trends, possible complications, and the effectiveness of multiple treatments. Keep your eyes and mind wide open to learn more about this advancing technology that will continue to support our efforts to bring health and well-being to our communities.This week we thank Hector Arreaza and Rosalynn Manophinives. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Obermeyer Z, Emanuel EJ. Predicting the Future - Big Data, Machine Learning, and Clinical Medicine. N Engl J Med. 2016;375(13):1216-1219. doi:10.1056/NEJMp1606181. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070532/.Rajkomar, Alvin, et al. "Scalable and accurate deep learning with electronic health records." npj Digital Medicine, 08 May 2018. https://www.nature.com/articles/s41746-018-0029-1Choi, Ellen, et al. "Retrospective analysis of real-world data to identify patients at risk for undiagnosed chronic obstructive pulmonary disease." PLoS ONE, 2020.Choi, Ellen, et al. "Machine Learning in Primary Care: Predicting Hospitalizations and Critical Events." AMIA Annual Symposium Proceedings, 2018.Beam AL, Kohane IS. Translating Artificial Intelligence Into Clinical Care. JAMA. 2016;316(22):2368-2369. doi:10.1001/jama.2016.17217. https://pubmed.ncbi.nlm.nih.gov/27898974/Johnson, Kipp W., et al. "Automated Fuzzy Cognitive Maps Generation for Supporting Clinical Decisions in Primary Care." IEEE Transactions on Fuzzy Systems, 2020.Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/

Episode 159: Transcranial Magnetic Stimulation BasicsFuture Dr. Ameri explains how transcranial magnetic stimulation can be useful in the treatment of certain mental conditions.  Written by Omeed Ameri, MS-IV, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Transcranial Magnetic Stimulation (TMS)TMS is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression and Obsessive-compulsive disorder (OCD). TMS uses the principles of electromagnetic inductions as described by Faraday’s Law. When an electric current passes through the TMS coil, it creates a rapidly charging magnetic field, which passes unimpeded through the scalp and skull, inducing a secondary current in neural tissues of the brain, causing depolarization of neuronal membranes in targeted brain regions, mainly in the superficial layers of the cortex 1.5 to 2.5 cm beneath the coil.How it works.Depending on the frequency and pattern of magnetic pulses, TMS can either increase or decrease cortical excitability. High-frequency TMS (Generally > 1 Hz) is associated with increased cortical excitability and is often used for depression treatment. In contrast, low-frequency TMS (This stimulation alters neurotransmitter release such as dopamine, serotonin, and norepinephrine. The repeated stimulation over sessions promotes synaptic plasticity, leading to more lasting changes in brain activity patterns associated with improved clinical outcomes. This is thought to have cascading effects throughout brain networks, and modulate dysfunctional circuits implicated in depression and restoring normal function. Effectiveness.The effectiveness of TMS can vary widely between individuals due to differences in anatomy, age, and specific conditions being treated. As such, ongoing research into how to personalize and optimize TMS parameters is ongoing. Research supporting the use of TMS in treatment-resistant depression.Research into the effectiveness of TMS and other therapy modalities targeting Treatment-Resistant Depression has been an ongoing effort for many years. In 2009, the American Academy of Family Physicians published Dr. Little’s article titled “Treatment-Resistant Depression,” which noted that there was little evidence that TMS could significantly treat patients with treatment-resistant depression. Since that time, the American Journal of Psychiatry published a groundbreaking study in 2020, led by Dr. Cole, which explores the effectiveness of a novel treatment for treatment-resistant depression. This trial, known as Stanford Accelerated Intelligent Neuromodulation Therapy or SAINT, which demonstrates promising results in combating depression where traditional methods have failed. It was an open-label study that provides a new perspective on depression treatment, emphasizing rapid and targeted intervention. Twenty-two participants received 50 intermittent theta burst stimulation (iTBS), which is a more recent protocol for TMS treatment, over the course of five days. Each session included 1,800 pulses per session, with a 50-minute intersession interval, ten times a day. As a result of this intensive regimen, one participant withdrew from treatment, and 19 of the remaining 21 met remission criteria, with a score of less than 11 on the Montgomery-Asberg Depression Rating Scale. There were no serious adverse events reported, the participant who withdrew did so due to anxiety. Side effects included fatigue and some discomfort. 70% of participants continued to meet response criteria one-month post-treatment.TMS application for patients with OCD. Studies have shown promising results for the treatment of OCD with TMS. Typically, OCD is difficult to manage and requires the highest doses of SSRIs. In 2019, The American Journal of Psychiatry published Dr. Carmi’s Article titled: “Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial”, which presents a comprehensive study on the effectiveness of dTMS in treating OCD. This multicenter, randomized, double-blind, placebo-controlled trial involved 99 OCD patients across 11 centers, who were treated with either high-frequency dTMS or sham dTMS, and focused on changes in the Yale-Brown Obsessive Compulsive Scale (YBOCS) scores.The treatment phase extended to 6 weeks with a total of 29 treatment sessions, following a 3-week screening phase and a 4-week follow-up phase. Patients were aged 22-68, with YBOCS scores greater than or equal to 20. At the start of the study, patients were already on a maintenance treatment with therapeutic dosages of SSRIs, or previously failed an SSRI and were currently being treated with Cognitive Behavioral Therapy. The results revealed that dTMS treatment participants showed a significantly greater reduction in YBOCS score compared to sham treatment (6.0 points vs. 3.3 points). The most frequent adverse effect was headaches. There was one incident of severe suicide ideation. On investigation, it was revealed that the suicide ideation preceded the treatment and required hospitalization for the patient. TMS therapy has shown promising results in treating both treatment-resistant depression and OCD. More research is required to assess the long-term viability of the treatment modality, and which treatment regimens have the greatest efficacy for various psychiatric disorders. I hope our listeners will keep TMS in mind when confronted with treatment-resistant depression and OCD.___________________Conclusion: Now we conclude episode number 159, “Transcranial Magnetic Stimulation,” also known as TMS. We learned from future Dr. Ameri that TMS has proven to be an effective option for treatment-resistant depression and Obsessive-compulsive disorder. When medications and therapy are not enough, you may consider this therapy for your patients. This week we thank Hector Arreaza and Omeed Ameri. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Cole, E., Stimpson, K. H., Bentzley, B. S., Gulser, M., Cherian, K., Tischler, C., Nejad, R., Pankow, H., Choi, E., Aaron, H., Espil, F. M., Pannu, J., Xiao, X., Duvio, D., Solvason, H. B., Hawkins, J., Guerra, A. T., Jo, B., Raj, K. S., . . .Williams, N. (2020). Stanford Accelerated Intelligent Neuromodulation Therapy for Treatment-Resistant Depression. American Journal of Psychiatry, 177(8), 716–726. https://doi.org/10.1176/appi.ajp.2019.19070720Carmi, L., Tendler, A., Bystritsky, A., Hollander, E., Blumberger, D. M., Daskalakis, J., Ward, H. E., Lapidus, K., Goodman, W. K., Casuto, L., Feifel, D., Barnea‐Ygael, N., Roth, Y., Zangen, A., & Zohar, J. (2019). Efficacy and Safety of Deep transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A prospective multicenter randomized Double-Blind Placebo-Controlled Trial. American Journal of Psychiatry, 176(11), 931–938. https://doi.org/10.1176/appi.ajp.2019.18101180Little, A. (2009, July 15). Treatment-Resistant depression. AAFP. https://www.aafp.org/pubs/afp/issues/2009/0715/p167.htmlRoyalty-free music used for this episode: If You Were the One, downloaded on November 15, 2023, from https://www.videvo.net/ 

Episode 158: Strength Training PrinciplesFuture Dr. Hasan explains the importance of adding muscle strength exercises to our routine physical activity. Dr. Arreaza asked questions about some terminology and reminded us of the physical activity guidelines for Americans.    Written by Syed Hasan, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.An Introduction to Strength Training Principles.Arreaza: Hello, everyone. Welcome to episode 158. [Introduce myself]. We are recording this episode right before Christmas but by the time you listen to this episode it will be 2024, so Happy New Year! It has been a busy time in our residency, we had lots of interviews, parties, and, of course, lots of learning and teaching. I apologize for our absence in the last few weeks, but we are back for good. We have Syed today, hi, Syed, please introduce yourself.Syed: Hi Dr. Arreaza, and hello everybody. My name is Syed. I am a fourth-year medical student at Ross University School of Medicine. I’m also a lifting enthusiast. One of my many goals in life is to look like I lift. Until I reach that goal, I will take solace in the fact that at least I sound like I lift. Arreaza: You are getting there, keep going! Give us an intro for today’s episode. Syed: (laughs) Thanks! Well, today, I want to present a framework with which to approach resistance training. The benefits of weight training are well-known, and a quick Google search gives us plenty to learn about them. But a clear framework for resistance training is a bit more difficult to come by. So, in this podcast, I will attempt to provide you, the listeners, with such a framework. By the end of the episode, my goal is to get most of you to start thinking about strength training seriously. Arreaza: I’m excited to hear it. I’m ready to learn more. I exercise, but I have to confess that I need to add more lifting to my routines. I enjoy cardio exercise, especially if I’m listening to my favorite music or watching a Netflix show. So, today I will go to bed being a little wiser. I have low gym literacy, but I think many of our listeners will appreciate my silly questions. Syed: (laughs) If you’re thinking it, it’s not a silly question, Dr. Arreaza! Before we begin though, some housekeeping. Because there is some technical stuff like names of muscles, their function, and exercises to target them, we will add a quick glossary at the end of the attached transcript. I will also include sources for the information I present. As well, a lot of other sources on hypertrophy training and exercise science. Arreaza: So, let’s start with the definition of strength training, Syed. Syed: Yeah. So put simply, any exercise where you produce force against a resistance can be thought of as a resistance training exercise. Doing this kind of exercise over a long period of time is what causes strength and muscle gain. By the way, strength and muscle gains are like chicken and eggs. Scientists are not sure which comes first, just that both are correlated. Practically, it means that when we look at two people, the person with bigger muscles is probably going to be stronger.Arreaza: On the Physical Activity Guidelines for Americans, available online at health.gov, we find that it is recommended that adults engage in “muscle-strengthening activities of moderate or greater intensity… [involving] all major muscle groups on 2 or more days a week,” and that’s ON TOP of the 150-300 minutes of moderate physical activity a week for general health benefits.Syed: Yeah, and we are talking about it today because a lot of times it’s unclear to people what such exercise entails. Some common examples are bodyweight exercises like push-ups, pull-ups, and squats. Syed: In these exercises, our body is the resistance against which our muscles are producing force. So, in push-ups, it is our chest and triceps that are mostly involved. In pull-ups, it is our back and biceps that work the hardest. When it comes to squats, it is our quads and glutes that are used most. Quads are the muscles in the front part of the thighs, and glutes are the buttock muscles. Arreaza: Push-ups, pull-ups, and squats are examples of bodyweight exercises. Syed: Yeah, so now let’s talk about free weight exercises. Just like in body weight exercises, we are using our body weight as resistance, in free weight exercises we use free weights, like barbells or dumbbells, as resistance. So, instead of a push-up, we could do a bench press with a barbell or dumbbell, for example. Arreaza: Barbells and dumbbells. What’s the difference?Syed: The difference is the size, dumbbells fit in your hand and barbells are larger. Bench press with them is a substitute for push-ups. These would target the chest and triceps just like push-ups. For pull-ups, the substitute would be barbell rows or dumbbell rows, to target the upper back. And the free-weight version of bodyweight squats is simply having a barbell on the upper back/shoulders and do squats. This exercise is called barbell squat. If we don’t have barbells but have dumbbells, we can grab one, hold it with both hands in front of our chest, and do squats. That is called a goblet squat.Arreaza: And don’t forget the kettlebells that can be used for squats too.Syed: That’s right. So far in our discussion, some themes have emerged. There are big muscle groups that work together, like the back and biceps, chest and triceps, and quads and glutes.There are exercise groups that target these muscle groups.These big muscle groups are either part of the trunk or are nearest to the trunk of the bodyMost people know what trunk is, but I’ll describe it as the area between the neck and groin. You can imagine our limbs and neck sprouting from our trunk just as branches sprout from a tree trunk.So, chest is part of the trunk, and biceps are near the trunk; back is part of the trunk, and triceps are near the trunk. For our lower body, quads and glutes are near the trunk.Now, let’s also summarize the muscle groups and exercise groups mentioned so far. Chest and triceps: Can be targeted with push-ups, bench press (when using barbells), or dumbbell press (when using dumbbells).By the way, in the world of lifting, the same exercise might have different names. I don’t want anyone to be married to the names. Understanding the movement pattern is the important thing.So, again, reiterate #1Back and biceps can be targeted with pull-ups, barbell rows, or dumbbell rows. There is also an exercise called lat pull-down that is like the movement pattern of pull-ups (basically starting with arms above our body and then bringing our elbows towards the ribs). But a lat-pull down uses a cable machine found at most gyms.So again, for back and biceps, we can do pull-ups, barbell or dumbbell rows, or lat pull-downs, depending on what we have access to.Finally, we talked about quads that can be targeted with body weight squats, barbell, or dumbbell squats. To these exercises, we can also add lunges, that can be done with bodyweight, dumbbells, or barbells.Arreaza: What are lunges?Syed: Lunges are like walking but you lower your hips and bend your knees with every step. And you do this with dumbbells in hands or a barbell on the back. You can also do it with just body weight. Arreaza: You said these muscle and exercise groups cover the big muscles on or nearest to the trunk. You have not mentioned the shoulders and the back of the thighs. Syed: To that, I would say, thank you for listening so closely! All of these exercises have been compound movements, meaning they target more than one muscle group. These are the exercises that give you the biggest bang for your buck, that is time.Syed: The compound exercises for back of the thigh is deadlifts. Muscles in the back of the thigh are called hams (short for hamstrings). The bread-and-butter compound exercise for hams is the deadlift. It can be done with a barbell or dumbbells. On top of targeting your hams, it also makes your erector muscles work hard. Erectors are also called erector spinae. These are a group of muscles in the back that work hard to keep your spine stable and help us stand straight. They also allow us to bend our spine side to side and even backwards a bit. So the deadlift is done with the lifter bending at the hips and knees, keeping the back straight. And reversing that movement to stand back up.Arreaza: It is important to exercise your erectors. Deadlifts for your hams. And for your shoulders?Syed: For shoulders, the go-to compound lift is the shoulder press (and again, this can be done with a barbell or dumbbell). It targets your delts, short for deltoids. Shoulder press also targets our triceps, traps, and upper chest. Syed: The thing with both deadlifts and shoulder press is that they are taxing on your spine. It’s true for squats too, but squats are a relatively simple movement compared to deadlifts and shoulder press. With deadlifts and shoulder press, you have to pay special attention to keeping a neutral spine, and that does not come intuitively. Often the best way to master these movements without putting your spine in a compromised position is under expert supervision, at least when learning the movement. Don’t get me wrong; it can be learned by paying close attention to exercise videos online as well. But yeah, it takes practice.Arreaza: So we have covered all big muscles groups that can be trained together using compound movements: back and biceps; chest and triceps; hams, erectors, and glutes; quads and glutes. Syed: Yes, glutes and abs are freebies. They get worked in a lot of movements. More directly in some exercises and less in others. So, these muscle groups really don’t need extra attention in most cases, at least not at the beginner level. So, now we know the muscle groups and the compound exercises to target these muscle groups. The final piece is how much and how often to train them. The recommended frequency, in general, for strength training is two days or more per week. Syed: How many exercises in a session? Generally, 3-5. Syed: How many sets for each exercise? The standard answer is 2-5 sets of 5-15 reps per exercise. Stopping 2-3 reps shy of failure (this is called the reps-in-reserve or RIR model). Make sure to take plenty of rest between sets. Arreaza: How much is plenty? Syed: 1) your muscles feel sufficiently recovered, 2) your breathing is back to normal or almost normal, and 3) your will to push for another set is back. You can use this 3-point checklist for both rest periods between sets and rest periods between training sessions. Between sets, the rest time may be 2 minutes; it may be 5 minutes. It may go from 5 to 2 minutes as your cardio improves over time. But the most important thing is, listening to our body.  Not overexerting. Otherwise, our subconscious is going to tell us, you just punish me when exercising. So, now it is going to rebel. And before we know it, weeks have passed between training sessions, we have lost the momentum for training, and we missed out on potential gains. Arreaza: My patients talk about being afraid of injuries when lifting. Can you talk about that? Syed: Anything in life has risks and benefits. I heard a resident at Rio Bravo once say, “being alive has its risks.” The good news is, resistance training of any kind, whether it is Olympic lifting, powerlifting, or bodybuilding, carries a lot less risk of injury compared to any other sport. And the benefits, physical, mental, and reduced all-cause mortality far outweigh the risks. I have never regretted a training session. This is something you will hear most people who lift say. And for good reason. The only thing is, start slowly, and increase weights slowly over time. Arreaza: Injury prevention is important. You need to make sure you are keeping a correct posture and body positioning during weight-lifting. A personal trainer can be a way to prevent injuries but if you are very motivated, you can find videos to guide you. Do you have any recommendations on sources where our listeners can learn more about this?Syed: To learn about the principles of muscle hypertrophy, the people I benefited the most from are Dr. Eric Helms, Dr. Mike Israetel,  Dr. Milo Wolf, and Barbell Medicine (Drs. Baraki and Feigenbaum whose articles I referred to when preparing for this podcast). All these people have tons of sources available in the forms of books, articles, YouTube videos, and Instagram posts. In other words, they are everywhere trying to teach us!. I can link some of the playlists for exercises by muscle groups.Arreaza: Thanks.Syed: Thank you for listening, I hope this episode gives us a better idea to guide our patients or ourselves in strength training. GlossaryCompound exercise A strength training exercise that involves the use of multiple muscle groups and joints to perform the movement. Chest Pecs or pectoralis muscles (major and minor)The pecs work to help us push things away in front of us.  Compound exercises targeting chest also work the front delts.  Triceps Tris (pronounced “tries”)The triceps help us straighten our arms.Chest and tris can be thought of as pushing muscles. ShouldersDelts or deltoids (front, medial, and rear) The delts raise arms up to around shoulder level, although some evidence suggests they work even when the arm has crossed the 90-100 degree mark. Back  Lats or latissimus dorsi helps us bring elbow close to our body (either from in front of us in a horizontal plane or from above us in a vertical plane). Most back exercises also work other muscles in the back like rear delts, traps, and erectors.GlutesGluteal muscles (gluteus maximus, medius, and minimus)Have many functions including pelvic stability, overall posture, force production in athletic movements, and so much more. Involved heavily in exercises for the quads and hams.  AbsCore or Abdominal muscles (rectus abdominis, internal and external obliques, and transverse abdominis)A group of muscles in the front of the torso. When body fat is low (10-15% in men and 15-25% in women), they lead to the appearance of the “six packs” (the rectus abdominis). They are used in most exercises when we brace before executing the movements.  Note: In most cases, being leaner than the percentages mentioned above is not good for overall hormonal health.   _____________________Conclusion: Now we conclude episode number 158, “Strength Training Principles.” Future Dr. Hasan explained how to strengthen groups of muscles by adding bodyweight and free weight exercises. He answered some questions about basic terminology and Dr. Arreaza added a few words about injury prevention. This week we thank Hector Arreaza and Syed Hasan. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Baraki A, Feigenbaum J, et al. Practical guidelines for implementing a strength training program for adults. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.). https://www.uptodate.com/contents/practical-guidelines-for-implementing-a-strength-training-program-for-adultsFranklin BA, Sallis RE, et al. Feigenbaum J, et al. Exercise prescription and guidance for adults. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.) https://www.uptodate.com/contents/exercise-prescription-and-guidance-for-adultsSullivan J, Feigenbaum J, et al. Strength training for health in adults: Terminology, principles, benefits, and risks. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on December 15, 2023.) https://www.uptodate.com/contents/strength-training-for-health-in-adults-terminology-principles-benefits-and-risksRoyalty-Free Music: Sur-La-Tabla_Beat. Downloaded on May 19th, 2023, from  https://www.videvo.net/Suggested Reading:Helms, E., Morgan, A., & Valdez, A. (2019). The Muscle & Strength Pyramid: Training. Muscle and Strength Pyramids, LLC.Helms, E., Morgan, A., & Valdez, A. (2019a). The Muscle & Strength Pyramid: Nutrition. Muscle and Strength Pyramids.Israetel, M. (2021). Scientific principles of hypertrophy training. Renaissance Periodization. Schoenfeld, B. (2021).Science and development of muscle hypertrophy. Human Kinetics.

Episode 157: Urine TestingThis episode includes the pitfalls of urine tests, how to detect adulterated urine, and more.  Written by Janelli Mendoza, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD. Comments by Carol Avila, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: Urine drug screenings are valuable tools used every day by physicians to monitor illicit substance use, as well as proper use or misuse of prescription drugs. However, studies suggest that physicians using “clinical judgment” on who and when to test is often wrong and confounded by implicit racial bias. The implications of this are an inappropriate discontinuation of treatment.For example, a study by Gaither, Gordon, and Crystal et. al found that compared to white patients, black patients were 10% more likely to undergo urine drug screening. In addition, they were 2-3 times more likely to have long-term opioid medication abruptly discontinued as a result of a UTOX positive for marijuana.False positive urine tests:Before getting into the current guidelines, let’s discuss the interpretation of Urine Drug Screenings. It’s important to be aware of prescription drugs that may cause false positives:· Bupropion, labetalol, pseudoephedrine, trazodone → Amphetamines· HIV antivirals, sertraline → Benzodiazepines· HIV antivirals, NSAIDs, PPI’s → Cannabinoids· Diphenhydramine, Naloxone, Quetiapine, Quinolones, Verapamil → Opioids· Dextromethorphan, diphenhydramine, ibuprofen, tramadol, venlafaxine → PhencyclidineTampering of urine: Other factors to consider are the tampering of collected urine. The tampering of collected urine may include diluting the urine, or adding other chemicals and substances. Laboratory results that should prompt consideration of adulteration are: Creatinine 11, Specific gravity 1.035, Temp 100 FHow long urine tests are positive:The detection window for common substances in urine drug screenings are as follows:· Amphetamines: 2-3 days· Cocaine: 1-2 days· Opioids: 1-3 days, but up to 14 days if the patient is on methadone.· Phencyclidine: up to or less than 1 week, may be longer if chronic use.Cannabinoids are a little different as the THC component builds up and is stored in adipose tissue. Therefore, a patient's weight, body fat percentage, exercise level, and diet can all influence the detection window. This is more so an issue for chronic daily users.· For single-time use: 2-3 days.· Daily use: 2-4 weeks· Chronic heavy use: >6-8 weeks as we said, the exact time will be influenced by many factors depending on how long it takes to deplete THC molecules stored in adipose tissue.Monitoring use of prescription drugs:Dr. John Hayes and Dr. Kristen Fox at the Department of Family Medicine and Community Medicine College of Wisconsin have developed a patient-centered approach in utilizing urine drug screenings for monitoring the use of controlled prescription drugs. If physicians should not test based on suspected misuse of medications, then when should they test? The frequency of screening should be determined based on a patient’s risk for substance use disorder. This will be determined by use of evidence-based tools such as a risk calculator. On MD calc, clinicians can find the ORT (Opioid Risk Tool for Narcotic Abuse) created by Dr. Lynn Webster. This stratifies patients into high-risk, moderate risk and low- risk of opioid related aberrant behaviors. Factors contributing to high-risk include age between 16-45, history of preadolescent sexual abuse, history of depression, history of ADD, OCD, Bipolar disorder, or schizophrenia, illicit substance use, history of misuse of prescription drugs. Family history also significantly contributes to risk assessment independently taking into consideration FHx of alcohol abuse, illicit substance abuse, and prescription drug misuse.How often can we test the urine for patients on controlled medications?Based on the risk assessment the frequency of Urine drug screenings for patients on controlled medications should be as follows:· Low- risk patients should be tested annually· Moderate-risk patients should be tested at least 2x per year· High-risk patients should be tested at least 3x per yearBased on the results, if it is found that a patient is recurrently misusing their medication, rather than abruptly discontinuing a patient off of their medication, it is recommended that the provider share their concern with the patient to initiate an open discussion. Medication should be tapered, and the patient should receive a referral and support from an addiction specialist.Unhealthy Drug Use: Screening by USPSTF (published on June 09, 2020):For adults age 18 years or older, the USPSTF recommends screening by asking questions about unhealthy drug use. Testing biological specimens is not recommended for this purpose. “Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.” Conclusion: Now we conclude episode number 157, “Urine Testing.” Future doctor Mendoza and Dr. Avila explained when to test your patients to verify their compliance with treatment. Urine tests need to be interpreted wisely. Make sure you establish a good relationship of trust with your patients and rule out other causes for a positive or negative urine test. For example, some patients may be positive for cannabinoids if they are taking certain medications such as PPIs. Dr. Arreaza also reminded us f the recommendation to screen for unhealthy drug use in adults by asking questions, not by testing biological specimens. This week we thank Hector Arreaza, Janelli Mendoza, and Carol Avila. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Recommendation: Unhealthy Drug Use: Screening, United States Preventive Services Taskforce, uspreventiveservicestaskforce.org, published on June 9, 2020. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/drug-use-illicit-screening.Argoff CE, Alford DP, Fudin J, et al. Rational urine drug monitoring in patients receiving opioids for chronic pain: consensus recommendations. Pain Med. 2018; 19:97-117. https://doi.oerg/10.1093/pm/pnx825.Gaither JR, Gordon K, Crystal S, et al. Racial disparities in discontinuation of long-term opioid therapy following illicit drug use among black and white patients. Drug Alcohol Depend. 2018;192:371-376.Kale N. Urine drug tests: ordering and interpreting results. Am Fam Physician. 2019;99:33-39.Saitman A, Park H-D, Fitzgerald RL. False-positive interferences of common urine drug screening immunoassays: a review. J Anal Toxicol. 2014;38:387-396. https://doi.org/10.1093/jat/bku075TAP 32: Clinical drug testing in primary care. Rockville, MD: Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services; 2012. Technical Assistance Publication (TAP) 32; HHS Publication No. (SMA) 12-4668. 2012.Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005 Nov-Dec;6(6):432-42. doi: 10.1111/j.1526-4637.2005.00072.x. PMID: 16336480.Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/ 

Episode 156: Obesity, Fertility, and PregnancyFuture Dr. Hamilton defines obesity and explains the pathophysiology of obesity and its effects on fertility and pregnancy. Dr. Arreaza adds some input about the impact of epigenetics on newborn babies.  Written by Shelby Hamilton, MS3, American University of the Caribbean School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition of obesityObesity is a multifactorial chronic disease that is increasing in prevalence across the globe. It can be defined as a body mass index (or BMI) greater than 30 kg/m2. According to the CDC from 2017-March 2020, the prevalence of obesity in United States adults was 41.9%.Classification of obesity by BMI.Obesity can further be divided into three classes: class I which is a BMI between 30-34.9; class II which is a BMI between 35-39.5; and class III which is a BMI greater than 40. We recommend avoiding the term “morbid obesity” because of the negative connotation of the word “morbid.” Class III or severe are better terms in those cases. This classification is based on the individual risk of cardiovascular disease. One of the greatest health consequences affecting individuals with obesity is the cardiovascular effects including hypertension, dyslipidemia, and coronary artery disease. Other effects include insulin resistance and diabetes, cholelithiasis, non-alcoholic fatty liver disease, osteoarthritis, and even depression.How Does Obesity Affect Fertility?Obesity can have an extensive effect on the overall health of an individual. In addition to these commonly discussed effects, obesity can also influence a person’s fertility. This is especially observed in women with polycystic Ovary Syndrome (PCOS) who have a greater BMI and also have symptoms of anovulation. Excess adipose tissue plays a role in the effects that obesity has on fertility. White adipose tissue can secrete a specific group of cytokines known as ‘adipokines’. These adipokines include leptin, ghrelin, resistin, visfatin, chemerin, omentin, and adiponectin. With a greater percentage of adipose tissue, there are higher rates of hypothalamic gonadotropin hormonal dysregulation, which can be combined with insulin-related disorders, low sex hormone binding proteins, and high levels of androgens. The combination of these factors can result in decreased ovarian follicle development and decreased progesterone levels.Hormonal changesObesity is an endocrine disorder. One specific adipokine that affects the hypothalamic-gonadotropin axis is chemerin. Chemerin impairs the release of follicle-stimulating hormone (FSH) from the pituitary gland. This reduction in FSH release consequently leads to anovulation, meaning that no egg will be released from an ovarian follicle, contributing to infertility. Shelby: Another adipokine affecting fertility is adiponectin. The receptors of adiponectin are predominantly expressed in reproductive tissues, including the ovaries and endometrium. In individuals with a greater BMI, a decrease in adiponectin secretion has been observed, resulting in decreased stimulation of its receptors, especially in the endometrium, which has been linked to recurrent implantation failure. Adiponectin has also been shown to affect glucose uptake in the liver. With reduced adiponectin levels, there is reduced hepatic glucose uptake, leading to insulin resistance. As tissues become less sensitive to insulin, the body compensates by secreting higher amounts of insulin, leading to hyperinsulinemia. Higher levels of circulating insulin have also been proven to cause hyperandrogenemia in women by blocking the hepatic production of sex hormone-binding globulin. Insulin can also act on the IGF-1 receptors in the theca cells, increasing steroidogenesis, and thus, increasing androgens. With hyperandrogenemia, there is also increased granulosa cell apoptosis as well as increased peripheral conversion of androgens into estrogen. This creates negative feedback to the hypothalamic-pituitary axis to decrease the release of gonadotropins such as FSH which are critical in ovulation.Leptin is another adipokine that is shown to be increased in obesity. Studies on mice have shown that leptin impairs the development of ovarian follicles, resulting in a decrease in ovulation. In these studies, it was also observed that leptin reduces the production of estriol by the granulosa cells in the ovarian follicles as well as increases the rate of apoptosis in granulosa cells, both of which affect ovulation. Leptin decreases hunger, but persons with obesity may be resistant to its effects and that’s why they have higher levels than a person with normal weight. They have high levels of leptin but are still hungry because they have leptin resistance.Studies have also shown that the fatty acid composition of follicular fluid found in ovarian follicles also plays a role in fertility. In individuals with a high BMI, this fluid contains high levels of oleic acid, which can cause embryo fragmentation after fertilization occurs. Stearic acid is another fatty acid found in elevated levels in the follicular fluid of women with a greater BMI, which can also affect the quality of the embryo while in the blastomere stage.The bottom line is obesity decreases fertility. It does not mean that patients with obesity will not get pregnant, but it can make it harder to get pregnant. Female patients who are losing weight must be warned about their improved fertility once they start to lose weight.What effect does obesity have on pregnancy?While obesity may make it more difficult for a woman to get pregnant, it is not impossible. However, there are potential risks both to the mother’s health as well as the baby’s health. Therefore, it is very important to monitor these patients even more carefully.Women who have a greater BMI pre-pregnancy are at a greater risk of developing gestational hypertension. Gestational hypertension is defined as blood pressure greater than 140/90 on more than one reading in the second half of pregnancy. Hypertension during pregnancy can also have serious complications such as kidney failure, stroke, myocardial infarction, or even heart failure. Gestational hypertension can also result in preterm birth or low birth weight.Treatment of mild hypertension in pregnancyRecent studies published in the AFP Journal support the treatment of mild hypertension in pregnancy. It states that “evidence and expert opinion support treating mild chronic hypertension in pregnancy with approved antihypertensives, with a strength of recommendation: B”. There was a randomized control trial with about 2,000 women who were randomized to receive antihypertensive treatment vs no treatment. The treatment group had a lower incidence of preeclampsia with severe features, preterm birth, placental abruption, and neonatal or fetal death. There was not an increase in fetal growth restriction or maternal or neonatal complications. So, it is advisable to treat chronic, mild hypertension in pregnancy, according to the AFP Journal.PreeclampsiaPreeclampsia is another condition that is at a higher risk in women with obesity, which is a more serious manifestation of hypertension in the second half of pregnancy. Along with high blood pressure, there are also effects on the kidneys and liver. Hypertension accompanied by proteinuria is indicative of preeclampsia and should be taken seriously. Preeclampsia can become eclampsia, where the patient also experiences seizures. There is also the risk for stroke, HELLP syndrome, placenta abruption, preterm birth, and fetal growth restriction.Gestational diabetesAnother risk is gestational diabetes. Elevated blood glucose during pregnancy can result in a larger baby and delivery by cesarean. There may also be a greater risk of the mother and child developing diabetes mellitus later on in life.OSAWomen with a greater BMI may also be at risk of developing obstructive sleep apnea during pregnancy. Not only can this result in fatigue but can also contribute to the development of gestational hypertension and preeclampsia.Effect of obesity on the fetusAs mentioned, there are some risks to the fetus in women with a greater pre-pregnancy BMI. There is a greater risk for these babies to be born with birth defects such as congenital heart defects and neural tube defects. Another risk previously discussed is macrosomia, or large for gestational age. Larger babies are also at increased risk for shoulder dystocia during delivery as well as resulting clavicle fractures, brachial plexus injuries, and nerve palsies. Preterm birth is another risk, which also increases the risk of short-term and long-term health complications. Lastly, a higher BMI is directly correlated with the risk of spontaneous abortion or stillbirth.SummaryAs the prevalence of obesity increases, it is important to discuss the health risks that are associated with this disease. In our patients of childbearing age and who may be hoping to conceive, it is even more important to discuss how a higher BMI may affect fertility and pregnancy. While discussing these topics with patients, it is important to try our best to build rapport with the patient so that the discussion is seen more as one of concern and support rather than one of criticism regarding their weight. We may want to help by not only telling patients to “lose weight” or “diet”, but we can also provide them with resources regarding dietary adjustments and ways they can incorporate physical activity into their lives without just telling them to eat less and move more. Stay tuned for our episode on the management of obesity in pregnancy.ConclusionNow we conclude episode number 156, “Obesity, fertility, and pregnancy.” Future Dr. Hamilton explained how obesity affects the hormonal regulation of fertility. She also explained the obstetrical risks associated with obesity. Primary care professionals need to educate our patients about the benefits of preconception weight control. Dr. Arreaza explained that hypertension is a common condition in pregnant patients with obesity and mentioned the benefits of treating mild hypertension in pregnancy. We hope to bring you an episode on the management of obesity in pregnancy soon, so stay tuned! This week we thank Hector Arreaza and Shelby Hamilton. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Gautam, D., Purandare, N., Maxwell, C., Rosser, M., O’Brien, P., Mocanu, E., McKeown, C., Malhotra, J., & McAuliffe, F. (2023) The challenges of obesity for fertility: A FIGO literature review. International Journal of Gynecology & Obstetrics, 160(S1), 50-55. https://doi.org/10.1002/ijgo.14538Pandey, S., Pandey, S., Maheshwari, A., & Bhattacharya, S. (2010). The impact of female obesity on the outcome of fertility treatment. Journal of Human Reproductive Science, 3(2), 62-67. https://doi.org/10.4103/0974-1208.69332.Perreault L. Obesity in adults: Prevalence, screening, and evaluation. In: UpToDate, Pi Sunyer FX (Ed) Wolters Kluwer. https://www.uptodate.com (Accessed on October 6, 2023).Obesity and Pregnancy FAQ, The American College of Obstetricians and Gynecologists (ACOG), https://www.acog.org/womens-health/faqs/obesity-and-pregnancy, Accessed on October 10, 2023.Adult Obesity Facts, Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/obesity/data/adult.html, Accessed on October 7, 2023. Dresang L, Vellardita L. Should Medication Be Prescribed for Mild Chronic Hypertension in Pregnancy?. Am Fam Physician. 2023;108(4):411-412. Royalty-free music used for this episode: "I Think We Have a Chance."  downloaded on November 11, 2023,  from https://www.videvo.net/.

Episode 155: Diabetic Foot Infection GuidelinesFuture Dr. Perez presents the updates on lung cancer screening by the American Cancer Society. Future Dr. Danusantoso explains the classification, diagnosis, and treatment of diabetic foot infections according to the guidelines published by the International Working Group on the Diabetic Foot (IWGDF). Dr. Arreaza adds comments and anecdotes.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro: Lung cancer screening update.Written by Luz Perez, MSIII, Ross University School of Medicine. Editing by Hector Arreaza, MD.Hello, my name is Luz Perez and today I will talk about lung cancer screening.As a reminder, lung cancer is the top cause of cancer-related death in men and women worldwide. In the United States, lung cancer causes the death of about 154,000 people each year[4]. Smoking is the most significant risk factor for developing lung cancer, a risk that directly correlates to how much and how long a person has smoked[2]. Despite the efforts to decrease lung cancer-related deaths, which include screening of patients at risk and counseling on smoking cessation, many patients go undiagnosed in part because lung cancer can be asymptomatic but also because many people at risk did not meet the criteria for screening, according to previous guidelines… BUT On November 1, 2023, the American Cancer Society updated its guidelines for lung cancer screening to decrease mortality by lung cancer in the US. The updated lung cancer screening guidelines were published in November, which is Lung Cancer Awareness Month. This guideline aims to expand eligibility criteria for lung cancer screening. Previously, the guidelines covered people only between the ages of 55-74 who were current smokers or had quit within the past 15 years and had a 30 or more pack-year smoking history[3].The new guidelines recommend annual screening with low-dose CT (LDCT) scan for people who are 50-80 years old who are current or former smokers and who have a 20 or more pack-year of smoking history [1]. This change means that about 5 million people who would previously not qualify for screening are now eligible for this potentially lifesaving screening exam.Additionally, the American Cancer Society emphasizes the significance of shared decision-making between patients and healthcare providers on lung cancer screening and smoking cessation. This includes ways to help patients stop smoking by providing counseling and interventions including medications. For patients who are eligible for screening, having a full discussion of the lung cancer screening process including the purpose of the procedure, risks and benefits of low-dose CT, and recommendations from other organizations, is key in the shared decision-making process[1]. Perhaps, the most important step in the implementation of these new guidelines is ensuring that medical professionals talk to their patients about them and make them aware of the importance of screening for lung cancer. In this way, we can reduce mortality and other consequences of this devastating disease. Written by Maria Danusantoso, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.Update to Guidelines for Treatment of Diabetic Foot InfectionsIntroductionIn October 2023, the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Disease Society of America (IDSA) collaborated and published an update to the 2019 guideline on the diagnosis and management of infections of the foot in persons with diabetes mellitus.The present guidelines include a list of 25 recommendations for diagnosis and management and clinically useful figures and tables including a treatment algorithm, a classification system for defining diabetic foot infections, and empirical antibiotic therapy according to clinical presentation and microbiological data.The goal of this episode is not to provide an exhaustive review of the updated guidelines and algorithms but to highlight what I believe are the most important recommendations. I hope this brief presentation is viewed as an introduction and that this encourages you, the listener, to independently read the guidelines in full and implement them into your own clinical practice.Wound Colonization Versus Wound InfectionBefore jumping into some of the recommendations, I want to take some time to discuss briefly how to classify diabetic foot infections. Most clinicians, including myself, will see a patient with diabetes with a foot ulcer or wound and want to treat it with antibiotics or admit the patient to the hospital. However, the updated guidelines propose that antibiotics and/or admission are not always indicated. For clinicians, there needs to be an awareness that wound colonization and wound infection are not the same. Wound colonization by bacteria is defined by the presence of bacteria on a wound surface without evidence of invasion of the host tissues. Colonization, then, can be considered a constant phenomenon as we live in a bacteria-filled world. Comment: If we culture our intact skin, we may find pathogens, that’s why wound cultures even if they are positive, do not indicate there is infection. Tell us about infection.In contrast, wound infection is a disease state caused by the invasion and multiplication of microorganisms in host tissues that induce an inflammatory response in the host, usually followed by tissue damage. Therefore, since all wounds are colonized – often with potentially pathogenic microorganisms – we cannot define wound infection using only the results of wound cultures. Instead, diabetic foot infections are a clinical diagnosis based on the presence of manifestations of an inflammatory process involving a foot wound located below the malleoli. These signs and symptoms of inflammation may be masked in persons with diabetes especially if they have some level of baseline peripheral neuropathy, peripheral artery disease, or immune dysfunction.Classification of Diabetic Foot Infections.To assist with the classification of diabetic foot infections, the updated guidelines include a table for defining the presence and severity of an infection of the foot in a person with diabetes. Again, diabetic foot infections are a clinical diagnosis, and the clinical classification of infection can be described as: 1) uninfected, 2) mild, 3) moderate +/- O if osteomyelitis is present, 4) severe +/- O if osteomyelitis is present. Uninfected has no systemic or local symptoms or signs of infection. Mild infection is when at least two of the following are present: local swelling or induration, erythema between 0.5-2 cm around the wound in any direction, local tenderness or pain, local increased warmth, purulent discharge, and there is no other cause of an inflammatory response of the skin present (e.g., trauma, gout, acute Charcot neuro-arthropathy, fracture, thrombosis, or venous stasis).Moderate infection is without systemic manifestations and involves erythema extending 2 cm or more from the wound margin and/or involves tissue deeper than skin and subcutaneous tissues (e.g., tendon, muscle, joint, and bone) +/- the presence of osteomyelitis. The surrounding erythema and the depth of wound are key element in the classification of the wounds. Severe infection is associated with systemic manifestations and meets systemic inflammatory response syndrome (SIRS) criteria as manifested by 2 or more of the following: temperature below 36°C or above 38°C, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute, white blood cell count greater than 12,000/mm3 or greater than 10% immature (band) forms +/- presence of osteomyelitis. Features of Osteomyelitis on Plain X-RayWe have mentioned osteomyelitis quite a few times in this episode, so what are some ways we can diagnose osteomyelitis? Most commonly, osteomyelitis is diagnosed via imaging either with plain X-rays  or MRI. When looking at plain X-rays, there are a few features that are characteristic of diabetes-related osteomyelitis of the foot of which we should be aware regardless of our status as radiologists. Some of these features include bone sclerosis with or without erosion, abnormal soft tissue density or gas density in the subcutaneous fat, or new or evolving radiographic features on serial images spaced several weeks apart such as loss of bone cortex, focal demineralization, periosteal reaction or elevation. Changes in x-ray may be a late finding and indicate that the osteomyelitis is established.General Treatment Recommendations for Diabetic Foot InfectionsIn the updated guidelines, recommendation 11 states to not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy when the goal is to reduce the risk of new infection or to promote ulcer healing. As previously said, diabetic foot infections are a clinical diagnosis. So if clinically the wound does not meet criteria to be classified as a mild, moderate, or severe infection, this recommendation proposes that no antibiotic treatment is the best treatment so as not to expose patients to potentially unnecessary and harmful treatment and to not promote antibiotic resistance in patients, which would potentially make treating diabetic foot infections more challenging in the future. We still want to very closely monitor the wound every 2-7 days and promote wound healing with pressure offloading, keeping the wound and the surrounding skin clean and dry, and other non-antibiotic management for local wound care.What are some common bacteria?.When it is indicated to treat diabetic foot infections per the guidelines, recommendation 14 states to target aerobic gram positive pathogens only for people with a mild diabetes related foot infection. These pathogens include beta hemolytic streptococci and Staphylococcus aureus including methicillin-resistant strains if indicated. Additionally, recommendation 15 advises not to empirically target antibiotic therapy against Pseudomonas aeruginosa in cases of diabetes-related foot infection in temperate climates. However, it is appropriate to use empirical treatment of P. aeruginosa if it has been isolated from cultures of the affected site within the previous few weeks or in a person with moderate or severe infection who resides in tropical/subtropical climates.Antibiotic Treatment Duration RecommendationThe final recommendation we have time to discuss in this episode is regarding antibiotic treatment duration. For mild infections, oral antibiotics (such as cephalexin or Bactrim) for a duration of 1-2 weeks is appropriate. However, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease, it is reasonable to consider extending treatment for up to 3-4 weeks.For moderate or severe infections without osteomyelitis, a total treatment duration of 2-4 weeks is recommended starting initially with IV antibiotics before transitioning to oral antibiotics. Antibiotic selection will depend on multiple factors, such as recent antibiotic use, or MRSA risk factors. For example, if the patient took antibiotics recently, they could receive Zosyn® and ceftriaxone. If osteomyelitis is present, antibiotic treatment duration can be anywhere from 2 days to 6 weeks depending on the amount of source control achieved. Ideally, we should wait to have bone resection before giving antibiotics, but we know that antibiotics are given promptly in the ER.In the cases of a resected infected bone or joint (when complete source control is achieved), a duration of 2-5 days is recommended, starting with IV antibiotics before transitioning to oral antibiotics. If there is minor amputation of the infected foot but there remains a positive wound culture or positive margins are seen on pathology (inflammatory cells are seen at the proximal margin of the amputated section), a 3-week antibiotic treatment duration is recommended, again starting with IV before transitioning to oral antibiotics.For diabetes-related foot osteomyelitis without bone resection or amputation, a 6-week course of antibiotics is recommended, again initially with IV antibiotics before transitioning to oral. In all the situations where there is a transition from IV to oral antibiotics, this transition may only occur once there are clinical signs of improvement, for example, improving erythema surrounding the wound, resolution of tenderness or purulent drainage, or SIRS criteria is no longer met.Summary: For more details regarding the 2023 update to the guidelines on the diagnosis and treatment of foot infection in persons with diabetes, please refer to the complete guidelines which can be accessed on the IWGDF Guidelines website and via the citations listed in the References. As a reminder, this podcast episode is not an exhaustive review of the guidelines, but, instead, a brief introduction to some of the recommendations. Thank you for listening and I hope you learned something new!_____________________________Conclusion: Now we conclude episode number 155 “Diabetic foot guidelines.” Future Dr. Perez started this episode with an introduction about the new guidelines to screen for lung cancer, then future Dr. Danusantoso gave an excellent summary about the classification and treatment of diabetic foot infections. Our patients with diabetes must have foot self-awareness and report any concerns to their family physicians or podiatrists so they can get prompt treatment.This week we thank Hector Arreaza, Luz Perez, and Maria Danusantoso. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:McDowell, Sandy, New Lung Cancer Screening Guideline Increases Eligibility. American Cancer Society, published on November 1, 2023, Cancer.org. https://www.cancer.org/research/acs-research-news/new-lung-cancer-screening-guidelines-urge-more-to-get-ldct.htmlWolf AMD, Oeffinger KC, Shih TY, et al. Screening for lung cancer: 2023 guideline update from the American Cancer Society [published online ahead of print, 2023 Nov 1]. CA Cancer J Clin. 2023;10.3322/caac.21811. doi:10.3322/caac.21811. Link: https://pubmed.ncbi.nlm.nih.gov/37909877/Moniuszko, Sara. Lung cancer screening guidelines updates by American Cancer Society to include more people. CBS News, updated on November 3, 2023. https://www.cbsnews.com/news/lung-cancer-screening-guideline-american-cancer-society-update/Deffebach, M. E., & Humphrey, L. (2023). Screening for lung cancer. UpToDate. Retrieved November 6, 2023, UpToDate. https://www.uptodate.com/contents/screening-for-lung-cancerÉric Senneville, Zaina Albalawi, Suzanne A van Asten, Zulfiqarali G Abbas, Geneve Allison, Javier Aragón-Sánchez, John M Embil, Lawrence A Lavery, Majdi Alhasan, Orhan Oz, Ilker Uçkay, Vilma Urbančič-Rovan, Zhang-Rong Xu, Edgar J G Peters, IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023), Clinical Infectious Diseases, 2023; ciad527, https://doi.org/10.1093/cid/ciad527Senneville, Éric et al. 2023. “IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Foot Infection in Persons with Diabetes.” IWGDF Guidelines. Retrieved November 6, 2023 (https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-04-Infection-Guideline.pdf). Royalty-free music used for this episode: Gushito, “Gista Mista”, downloaded on November 16th, 2023, from https://www.videvo.net/ 

Episode 154: Heart Failure and GDMTDr. Malave explains the four main medications that are part of the guideline-directed medical therapy of heart failure with reduced ejection fraction. Dr. Arreaza added comments and questions.  Written by Maria Fernanda Malave, MD. Edits by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Brief introduction: Heart failure (HF) is a common condition that affects about 23 million people in the world, and it is estimated that 50% of cases are due to heart failure with reduced ejection fraction (HFrEF). It is a major public health concern because of the high morbidity and mortality with a 5-year survival rate of 25% after hospitalization due to HFrEF.In recent years, the management of HFrEF has evolved due to increased evidence in favor of certain medications. Guideline-directed medical therapy (GDMT) is the foundation of medical therapy for these patients, and it is the result of multiple randomized controlled trials and reviews favoring four main drug classes: 1. renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors -ACEi- and angiotensin receptor blockers -ARB), 2. evidence-based β-blockers, 3. mineralocorticoid inhibitors, and 4. sodium-glucose cotransporter 2 inhibitors -SGLT-2i-. The benefit of this therapy is mostly seen when these four groups of medications are used in conjunction. During this episode, we will provide some key elements about the prescription of these medications, but this is only an overview, and you are invited to continue learning from reputable sources.Definitions: HF is defined as the impairment of the heart to meet the metabolic demands of the body. It can be caused by multiple conditions that interfere with the filling up of the heart or conditions that prevent an effective ejection of blood out of the heart. Classification of HFrEF: Based on the EF by echocardiogram, heart failure can be classified as:Heart failure with preserved ejection fraction (HFpEF) when the EF is 50% or more.Heart failure with mildly reduced ejection fraction when EF ranges between 41-49%.Heart failure with reduced ejection fraction (HFrEF) when EF is 40% or less.GDMT: Once we make the diagnosis of HF, it is key to educate our patients and re-educate them every single visit about the importance of guideline-directed medical therapy (GDMT) and lifestyle modifications, because this can change the prognosis and exacerbation rates. Many patients think that since they are feeling well after starting GDMT they can stop it, but that’s going to increase exacerbations, hospitalizations, and decrease quality of life. Key points to discuss with patients.First, discuss that GDMT are disease-modifying drugs that regulate the neurohormonal system to stop the progression of the disease. We should explain to our patients that medications should be taken despite feeling well. Also, patients should be educated about regular follow-ups and medication titration. We can even instruct our patients about increasing their furosemide dose if they observe signs of overload, such as a weight increase of 2-3 kgs in 3-4 days, tight rings, socks or bracelets, also Paroxysmal nocturnal dyspnea, dyspnea on exertion, and more.  Second, lifestyle modifications such as: quit smoking and alcohol. Additionally, in general, water restriction between 1.2-1.5L daily, salt restriction (there is no official recommendation about how many grams, but in general we recommend less than 2g daily). Third, it is highly recommended to do aerobic exercise that produces mild dyspnea since this improves cardiovascular capacity and decreases hospitalization risk. Patients should be encouraged to have their annual influenza vaccine and pneumococcal vaccine according to their own immunization schedule. According to the AFP journal, in September 2022, researchers found a clinically and statistically significant reduction in all-cause mortality for patients who received an influenza vaccine right after an MI, with a number needed to treat of 50, the effectivity of the vaccine may vary by season.GDMT, groups of medications:What are the basic medications any patient with HF should be on? At least, patients should be on angiotensin receptor blockers ARBs/ACEIs and Beta-blockers. Let’s keep in mind that beta-blockers should be given cautiously in cases of exacerbation, but in general low doses are safe. We also have the angiotensin receptor/neprilysin inhibitors (ARNIs), a group of medications whose representative is the combination of sacubitril/valsartan, aka Entresto®. This medication should be the target once ARBs/ACEIs are tolerated. ARBs/ACEIs/ARNIs should be discontinued in the setting of advanced CKD, with a GFR of 30 or less. This applies to other medications used in HF such as SGLT-2 and mineralocorticoid receptor antagonist (MRA, such as spironolactone/eplerenone). Remember that SGLT-2 inhibitors should be started regardless diabetes status, and BB are safe in the setting of CKD. We also have other groups that are considered safe in patients with advanced CKD such as hydralazine/isosorbide dinitrate (combined or not), which are used in African Americans whose BP and HF symptoms do not improve with maximally tolerated dose of ARBs/ACEIs + BB.Ivabradine: Let’s not forget about ivabradine, which is an SA node inhibitor like BB. Patients need to meet criteria such as a maximally tolerated dose of beta-blocker, heart rate of a least 70 or more and being on normal sinus rhythm to be started on this medication. Ivabradine does not improve survival as BB do, so even though they are not contraindicated in HF exacerbation, BB are still preferred since ivabradine does not decrease mortality.Titration and follow-ups in the HF management:-ARBs/ACEIs/ARNIs should be titrated approx. Q2 weeks until the maximally tolerated dose is achieved, ARNI should be titrated up Q2-4weeks. With these medications, we should monitor BP, potassium levels and Glomerular Filtration Rate (GFR). -BB can also be titrated up Q2weeks until the maximally tolerated dose is achieved. HR, BP and signs of congestion should be observed in patients on BB. Same for hydralazine/isosorbide, with BP follow-up. -MRA, such as spironolactone/eplerenone, these meds can be added in patients who remain symptomatic despite maximally tolerated doses of “ARBs or ACEIs or ARNIs” plus Beta-blockers. For MRA, potassium level, and GFR should be monitored every 2-3 days after initiation, 7 days after titration, monthly for 3 months, and then Q3 months. To start a patient on MRA, K+ must be lower than 5.Patients with HF should be followed up at least in a 2-week interval either via telephone, telemedicine, or clinic visit to assess symptoms, vital signs, bloodwork and to perform a physical exam. Monitoring EF: After 3-6 months of the patient´s stabilization, we should reorder an echo, EKG, BNP and Basic Metabolic Panel. The ejection fraction improves in all patients after GDMT initiation and compliance, and in some patients, this improvement is very significant, so we need to reassess EF after stabilization. Comorbidities: Also, let´s keep in mind that most of the patients have associated comorbidities such as Afib, diabetes, valve disease, or anemia. These comorbidities must be addressed either by starting anticoagulation, adjusting anti-diabetes medications, starting iron, or referring to cardiology if a valve replacement is needed.When to refer to Cardiology? Some patients will qualify for device therapy (ICD) as a primary prevention for ventricular arrhythmias that can degenerate either into torsades or ventricular fibrillation. These patients must be symptomatic, at least in 3 months of maximally tolerated GDMT, and EF between 30-35%. Symptomatic Other criteria to refer a patient to the cardiologist are: patients resistant to GDMT despite target or maximally tolerated doses, or with worsening symptoms, two or more hospitalizations in 12mo, low blood pressure, tachycardia, and end-organ failure. __________________________Conclusion: Now we conclude episode number 154, “Heart Failure and GDMT.” Remember that GDMT can improve not only the symptoms of heart failure with reduced ejection fraction, but it can also improve mortality. The four main classes of medications are renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid inhibitors, and SGLT-2 inhibitors.This week we thank Hector Arreaza and Maria Fernanda Malave. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Murphy SP, Ibrahim NE, Januzzi JL Jr. Heart Failure With Reduced Ejection Fraction: A Review [published correction appears in JAMA. 2020 Nov 24;324(20):2107]. JAMA. 2020;324(5):488-504. doi:10.1001/jama.2020.10262. Link: https://pubmed.ncbi.nlm.nih.gov/32749493/Patel J, Rassekh N, Fonarow GC, et al. Guideline-Directed Medical Therapy for the Treatment of Heart Failure with Reduced Ejection Fraction. Drugs. 2023;83(9):747-759. doi:10.1007/s40265-023-01887-4. Link: https://pubmed.ncbi.nlm.nih.gov/37254024/Royalty-free music used for this episode: Latin Chill, downloaded on July 20, 2023, from https://www.videvo.net/.

Episode 153: Sudden Infant Death Syndrome.    Future doctors Nisha and Afolabi explain the way to prevent sudden infant death syndrome and Dr. Arreaza adds comments about prevention through vaccines.  Written by Selena Nisha, MS4; and Oluwatoni Afolabi, MS4. Ross University School of Medicine. Comments by Hector Arreaza, MDYou are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today, we are going to talk about sudden infant death syndrome, also known by its acronym SIDS. This topic is a heavy one and it may be triggering for some parents or those who may personally know a family member affected by SIDS, so please refrain from listening to this podcast at any point you see fit. First and foremost, we tend to hear a lot about SIDS in the news or social media outlets that cover these tragic incidents, but let's define what exactly sudden infant death syndrome is. Sudden Infant Death Syndrome, or SIDS, is the abrupt and unexplained death of an infant It occurs mostly between 1-3 months. Q: What causes SIDs? The exact cause of SIDS is unfortunately unknown. However, there are many studies that have identified several risk factors for SIDS and most of them are definitely preventable. The most important risk factors for SIDS are related to the sleep position and the sleep environment of the baby. Babies placed to sleep on their side or their stomach are at increased risk for SIDs compared to babies placed to sleep on their back. In addition, bed-sharing is also strongly associated with increased risk for SIDs.Smoking during pregnancy and postnatal exposure to tobacco. Second-hand smoking exposure is probably the most important risk factor for SIDS.Drug use or alcohol use during pregnancyOverdressing/overheating the babyBabies that are born premature and/or low birth weightLate or no prenatal care.Q: Are there any ethnic or genetic components involved in SIDS? Yes, there are. According to the CDC, African American, American Indian or Native Alaskan babies have a higher risk.Surprisingly, some studies have even shown an increase in SIDS in baby boys compared to baby girls and if a baby’s sibling had died of SIDS, that may be linked to a genetic disorder.Asian babies are less likely to suffer from SIDS, and African Americans are disproportionally affected by SIDS.Interesting fact: Several people have been accused of killing their own babies and later forgiven because a diagnosis of SIDS was established after autopsy and extensive investigation. Some examples are: Kathleen Folbigg (Australia), Sally Clark (England), and Angela Cannings (UK).Q: What are the clinical recommendations to reduce the risk of SIDS that parents and caregivers should be aware of?It is important to know that although short episodes of tummy time are beneficial for the baby, we need to be sure to not put the baby to sleep on their belly or side. In fact, the incidence of SIDS has decreased more than 50% in the past 20 years, largely as a result of the “Back to Sleep” campaign in 1992 that recommended that babies be placed on their backs to sleep to reduce the risk of SIDs.When choosing a crib and mattress, make sure you pick a crib that is well made and sturdy and a mattress that is firm and flat. It is important for the angle of the mattress to not be higher than 10 degrees. I know that we all love to see fluffy and cute little blankets and toys in the baby’s crib, however, we also need to make sure none of those things are present while the baby is sleeping in order to avoid any chance of suffocation.Q: A friend of mine who recently had a baby always feels anxious when breastfeeding her baby because she feels that her baby is not getting enough air to breathe in. She actually feels the same way when her baby is using the pacifier too. Is it true that the baby is truly struggling to breathe in these instances? This is a common misconception that many mothers tend to have. Many women genuinely fear that their baby isn’t properly breathing while breastfeeding and are worried that this can increase the risk of SIDS. However, the opposite is actually the truth. Turns out that breastfeeding for 6 months to a year actually decreases the risk of SIDS.We know that many parents make use of pacifiers, especially in situations relating to soothing the baby but interestingly enough, pacifiers can decrease the risk of SIDS as well. The only important thing to know about pacifier use is that if the baby does not want the pacifier, please don’t force it. Also, make sure the pacifier does not have any hanging parts to it such as cords or straps and if they are sleeping, be sure to not put the pacifier back in the mouth.Q: After listening to all of these recommendations, it seems like the baby should be sleeping with the parents in the first year of life just to be sure nothing happens to them. This way, the parents will be able to jump into action as quickly as possible because they will be right next to the baby. As safe as this sounds to me, is co-sleeping even recommended?It may seem like a good idea in retrospect however studies have shown that co-sleeping in an adult bed can actually increase the chances for SIDS. Although there may be many reasons as to why parents choose to have their baby in bed with them, we need to try to refrain from co-sleeping with the baby. It is definitely okay to have them sleep in the same room as you, but make sure they are in a bassinet or someplace nearby instead of sleeping in your actual bed. There are risks involved that you may not think can occur but certainly have in past cases such as accidentally rolling over on your baby or the baby may become trapped between the headboards if there is empty space present.Q: These are some excellent recommendations and very helpful tips that parents will be able to utilize when prepping for the baby and after the baby arrives. Luckily, we have many well-known baby cameras and devices that can also be put into place to ensure that the baby is safe. Do you think this is enough to be reassured? There are many baby monitors and devices on the market currently that claim to help reduce the risk of SIDS. While that may seem true, I would argue that nothing is more reliable than utilizing the safe sleep practices we mention here today as no device or monitor can do the same.Q: Who can parents talk to if they aren’t sure that what they are doing is right or if they need more help in figuring out ways to practice safe sleep? This is what your well-baby visits are for. Parents can always verbalize their worries or questions to their pediatricians during the visits. As important as it is for doctors to make sure that the babies are developing well, it is also their job to make sure your questions and concerns are taken care of.Q: How exactly is the diagnosis of SIDs made, especially since many of these risk factors seem majorly accidental?It is important to note that there is no specific diagnostic test for SIDs. The diagnosis of SIDs is made only when all other causes have been ruled out following a thorough clinical history, death scene investigation, and autopsy. It is a postmortem diagnosis.Clinical history is gathering all information about the infant which includes certain lab work or other studies that may have been abnormal during their life. As we have mentioned, it is very important to rule out all the other possible causes of death before making a SIDS diagnosis.Not only is the clinical history important, but the death scene is also crucial to making a diagnosis as well. Some may think that just by looking at the scene you will be able to figure out exactly how the death occurred. But that is not always the case. There are certain parameters officers and investigators have to follow prior to coming to a conclusion. For instance, some may use a doll to demonstrate the position of the baby in certain instances where the baby may have been in a crib that was not well made or if they were wedged between objects.Other things to ask would be when the baby was awake and when they went to sleep, where they were found, what time they were found. If they happen to be found in a bed, it is important to ask how many people were on the bed sleeping with the baby and how firm or soft the actual mattress was that the baby was sleeping on. Other things to observe are what type of bedding did the crib or bed have and what clothes the baby had on.Q: There were so many factors to consider after death. Selena, what would the autopsy show at this point that would lead to SIDS being the cause of death?First, we have to make sure there is no evidence of trauma or anything that points to abuse externally. Some external findings for SIDS could be fluid in the nose that is tinged with blood or it may even look frothy. The infant itself should look well-developed. Internal findings could be upper respiratory tract inflammation, congestion or pulmonary edema, petechiae in the intrathoracic region or hepatic hematopoiesis that is persistent. After hearing about all this, if I ever have my own baby, I would feel so afraid to leave them with anyone but me.Please don’t feel this way. This information is not meant to scare you. There are many caregivers and family that have a ton of love for the baby and would be more than happy to take care of them. I would say to set boundaries and ask questions about how your baby will be cared for when you are not around. This will bring you lots of ease that your baby is in safe hands. Sometimes it is very important to remind our family or caregivers the proper safe sleep practices, especially if it has been a while since they’ve been around a baby.Q: How can boundaries be set in a way that doesn’t seem offensive? What are some questions parents can ask or what can they do before leaving their baby in the care of someone else? Encourage parents to not feel afraid to ask questions. That is the best thing you can actually do to ensure your needs are being met for safe sleep. Let me give you some examples of questions to ask that will be direct, but in no way will it seem offensive.Ask what sleeping arrangements they have for your child in their home. There is no harm in providing your own if you feel that the arrangements are not safe.If the baby happens to fall asleep in things like a car seat or bouncer, ask them what they would do upon seeing that.Be sure to ask in what position they put the baby to sleep and remind them that babies should only be sleeping on their backs. Ask them where tummy time will be taking place and make sure to see the location yourself.Since we can’t control the people who are around or go into the caregivers' house, it is crucial to ask if anyone who tends to smoke tobacco or use vaping products will be in the vicinity of the baby. This is especially important to ask as many people may not consider this to be harmful to the baby, but even secondhand smoke increases the risk for SIDS greatly. Q: How to approach parents affected by SIDS?These families are truly living their worst nightmare. It is a situation that you or I cannot even fathom being in. It is very heartbreaking for all those involved especially since the deceased is such a young baby that had more life to live. First and foremost, it is very important that the parents have a good support system.Be sure to show compassion and empathy. This goes a very long way. Simple things such as saying, “I am here for you”, “I am so sorry for your loss”, “I can’t even imagine what you’re going through”, “please, let me know if there is anything I can help you with during this time”, or “I am here if you need to talk” will allow the parents to feel supported and their emotions to feel validated. Just being there is a huge step in the right direction to help a family who is processing all of this trauma and tragedy.SIDS is definitely a traumatic event in a family. Let’s not forget about vaccinations to reduce the risk of SIDS. I’m glad that the incidence has been decreasing in the last decades thanks to research. Let’s wrap up this episode.Vaccines: The CDC recently recommended RSV vaccination to all pregnant women between 32 through 36 weeks of pregnancy from September through January.The diagnosis of SIDS requires the exclusion of other causes of death, including investigation of the death scene and autopsy.Prevention is key. The most evidence-based preventive measures are back sleeping, pacifier use, breastfeeding, and proper bedding, and avoid co-sleeping. If you made it to the end of this episode, I really hope you can take some of these tips and recommendations and apply them to your practice and share this useful information to your patients who are family planning or those with infants. We know it is such a difficult topic to bring up to patients but it is very important to let them know how to prevent SIDS and the unfortunate consequences that can come out of not practicing safe sleep. ______________________________Conclusion: Now we conclude episode number 153, “Sudden Infant Death Syndrome.” Future Doctors Nisha and Afolabi explained how to prevent SIDS. Evidence supports some preventive measures such as: avoiding second-hand smoke exposure, avoiding co-sleeping, and avoiding overdressing and overheating of the baby. The preferred sleeping position for babies is on their backs. Dr. Arreaza also emphasized the prevention of SIDS by giving appropriate vaccinations to infants. Dr. Schlaerth highlighted the importance of proper beds and bedding for babies. Remember to recommend parents use a firm mattress for cribs and avoid blankets, stuffed animals, or any other items on babies’ beds that could cause accidental suffocation.This week we thank Hector Arreaza, Selena Nisha, Toni Afolabi, and Katherine Schlaerth. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Adams SM, Ward CE, Garcia KL. Sudden infant death syndrome. Am Fam Physician. 2015 Jun 1;91(11):778-83. PMID: 26034855. https://www.aafp.org/pubs/afp/issues/2015/0601/p778.htmlCenters for Disease Control and Prevention (CDC). CDC Grand Rounds: Public Health Approaches to Reducing U.S. Infant Mortality. MMWR Morb Mortal Wkly Rep. 2013;62(31):625-628. https://www.cdc.gov/grand-rounds/pp/2012/20121016-infant-mortality.htmlMitchell EA, Ford RP, Stewart AW, et al. Smoking and the sudden infant death syndrome. Pediatrics. 1993;91(5):893-896. https://pubmed.ncbi.nlm.nih.gov/8474808/Kim H, Pearson-Shaver AL. Sudden Infant Death Syndrome. 2023 Jul 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 32809642. https://www.ncbi.nlm.nih.gov/books/NBK560807/Bass M, Kravath RE, Glass L. Death-scene investigation in sudden infant death. N Engl J Med. 1986;315(2):100-105. doi:10.1056/NEJM198607103150206. https://pubmed.ncbi.nlm.nih.gov/3724796/Berry PJ. Pathological findings in SIDS. J Clin Pathol. 1992;45(11 Suppl):11-16. https://pubmed.ncbi.nlm.nih.gov/1474151/Moon RY, et al. Task Force on Sudden Infant Death Syndrome and the Committee on Fetus and Newborn. Sleep-related infant deaths: Updated 2022 recommendations for reducing infant deaths in the sleep environment. Pediatrics. 2022; doi:10.1542/peds.2022-057990. https://publications.aap.org/pediatrics/article/150/1/e2022057990/188304/Sleep-Related-Infant-Deaths-Updated-2022?autologincheck=redirectedSafe Sleep NC. (2019, September 13). Talking to Families about Safe Sleep - Safe Sleep NC. https://safesleepnc.org/healthcare-providers/talking-to-families-about-safe-sleep/Royalty-free music used for this episode: Latin Chill, downloaded on July 20, 2023, from https://www.videvo.net/.

Episode 152: ALS FundamentalsFuture Dr. Rodriguez explains the symptoms of ALS, including UMN and LMN symptoms. Dr. Arreaza discusses the principles of symptomatic treatment by primary care. This is a brief introduction to ALS.  Written by Adraina Rodriguez, MSIV, Ross University School of Medicine.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: It is rare but you may encounter it and you should be able to identify the most common symptoms. ALS Challenge in 2014: Ice bucket challenge. Adriana: Patrick Quinn was an ALS patient and activist who created the ICE Bicket Challenge and helped raise US$220 million for medical research.Arreaza: What is ALS?Adriana: ALS stands for Amyotrophic Lateral Sclerosis, formerly known as Lou Gehrig’s Disease. It is the most common form of acquired motor neuron disease. ALS is a progressive, incurable neurodegenerative motor neuron disorder with Upper motor neuron (UMN) and/or Lower motor neuron symptoms that cause muscle weakness, disability, and eventually death. There is no single diagnostic test that can confirm or entirely exclude the diagnosis of motor neuron disease. Arreaza: When should you suspect ALS in a patient?Adriana: The classic patient presentation is insidious, slowly progressive, and unremitting UMN and/or LMN symptoms present in one of four body segments - cranial/bulbar, cervical, thoracic, and lumbosacral - followed by spread to other segments over a period of months to years. Arreaza: What would you see on the physical exam when the Patient is in the clinic? There is a system to send signals from your brain to your muscles. It involves basically two neurons: Upper and lower motor neurons. The UMN goes from your cerebral cortex to your spinal cord and there it connects to a lower motor neuron through synapsis. The LMN then sends the signal to your muscles, causing contraction or relaxation. Tell us about the UMN and LMN symptoms.Adriana:LMN Symptoms: Weakness, Fasciculations, Muscular atrophy, Decreased muscle tone (flaccidity) and reduced or absent reflexes. UMN Symptoms: Increased tone and increased extremity deep-tendon reflexes, presence of any reflexes in muscles that are profoundly weak and wasted, pathological reflexes (crossed adductors, jaw jerk, Hoffman sign, Babinski sign 50%), syndrome of pseudobulbar affect (inappropriate laughing, crying, forced yawning).Arreaza: What are important factors to help narrow your differential to ALS?Multifocal motor neuropathy, cervical radiculomyelopathy, benign fasciculations, inflammatory myopathies, post-polio syndrome, monomelic amyotrophy, hereditary spastic paraplegia, spinobulbar muscular atrophy, myasthenia gravis, hyperthyroidism, and many others.There are pertinent negatives to look out for: Usually negative neuropathic or radiculopathic pain, sensory loss, sphincter dysfunction, ptosis, or extraocular muscle dysfunction (20-30% positive sensory symptoms or “pins and needles” and “electricity” in the affected limbs).Note: Cognitive dysfunction does not exclude ALSArreaza: What are the diagnostic criteria for ALSAdriana: Gold Coast Criteria 2019 proposed over El Escorial criteria:Progressive upper and lower motor neuron symptoms and signs in one limb or body segment, ORProgressive lower motor neuron symptoms and signs in at least two body segments, ANDAbsence of electrophysiologic, neuroimaging, and pathologic evidence of other disease processes that might explain the signs of lower and/or upper motor neuron degeneration.Arreaza: What diagnostic tests should be ordered for further evaluation?Adriana: Electrodiagnostic studies: Electromyogram and nerve conduction studies (EMG and NCS)Laboratory testing: creatine phosphokinase up to 1000u/LNeuroimaging: to exclude other causes mainly. Brain MRI whenever bulbar disease is present. Cervical and lumbosacral spine MRI for LMN findings in the arms and legs.Genetic testing: FALS 10% of ALS defect in C9ORF72 gene that makes motor neuron and brain nerve cell protein, the exact cause is unknown. Arreaza: Finally, how do you treat ALS?Adriana: Disease-modifying treatment: Riluzole is recommended for all patients with ALS. Shown to prolong survival and slow functional deterioration. The mechanisms of action that reduce glutamate-induced excitotoxicity: 1) inhibit glutamic acid release, 2) non-competitive block of N-methyl-D-aspartate (NMDA) receptor-mediated responses, 3) direct action on the voltage-dependent sodium channel. Arreaza: Riluzole is given 50 mg by mouth twice a day. It may cause drowsiness or somnolence, hepatic injury: Not recommended for patients with elevation of transaminases >5 times the upper limit of normal. It is recommended to monitor for hepatic injury and discontinue if there is evidence of liver dysfunction, such as hyperbilirubinemia.Adriana: Symptom-based management is the mainstay of treatment. You may involve a multidisciplinary team to treat the symptoms. For example: palliative, hospice, respiratory function management (Noninvasive Positive Pressure Ventilation vs mechanical ventilation.Arreaza: PCPs may be in charge of managing symptoms because you are the closest provider to the patient. Wherever available, it is recommended to refer your ALS patients to a specialized center. Many patients do not have availability to an ALS center or a neurologist, but they have you to manage their symptoms or complications.Adriana: Dysphagia: It is a common and distressing symptom. It is suggested PEG tube placement for patients with ALS with normal or moderate respiratory function who have dysphagia. It is controversial, some studies found no benefit on survival or quality of life and other studies suggest that it is safe to give a high-carb, hypercaloric diet to ALS patients. Arreaza: Spasticity: Use medications such as baclofen and tizanidine may be helpful, and botulinum injections are an option for those who are not responding to oral muscle relaxants. Adriana: Sialorrhea: Use medications such as atropine, hyoscyamine, amitriptyline, and scopolamine. If these medications are not effective or tolerated, used botox injections into the salivary glands. It is considered safe and useful for treating sialorrhea in patients with ALS. Botox is not only for wrinkles!Arreaza: There are many other symptoms that will require management, but you are invited to review your preferred source of information such as Up to Date, AAFP, or the ALS Association website. ______________________________Conclusion: Now we conclude episode number 152, “ALS Fundamentals.” You heard from future Dr. Rodriguez that ALS can present with upper motor neuron symptoms, such as spastic muscles and hyperreflexia; or lower motor neuron symptoms, such as flaccid and weak muscles. Some other symptoms include dysphagia, shortness of breath, difficulty talking, fatigue, thick mucus, and pseudobulbar affect. Dr. Arreaza explained that primary care physicians are in a special situation to help diagnose and treat the symptoms of ALS, especially in communities with limited access to an ALS center. You may need to involve a multidisciplinary team to improve the quality of life and possibly the survival of ALS patients. This week we thank Hector Arreaza and Adriana Rodiguez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Galvez-Jimenez, Nestor and Colin Quinn, Symptom-based management of amyotrophic lateral sclerosis, Up To Date, updated on July 31, 2023. https://www.uptodate.com/contents/symptom-based-management-of-amyotrophic-lateral-sclerosis. Royalty-free music used for this episode: Good Vibes: Sky's The limit, downloaded on July 20, 2023 from https://www.videvo.net/ 

Episode 151: Martian Medicine 102Future Dr. Collins discussed with Dr. Arreaza two common complications of astronauts in a hypothetical travel to Mars: Spaceflight-Associated Neuro-ocular Syndrome and mental illness.  Written by Wendy Collins, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: We are back for another episode of Martian Medicine! A couple months ago we published the episode Martian Medicine 101. We talked about radiation and its health risks for astronauts going beyond Low Earth Orbit such as a crew going to Mars. Today, we are going to be covering Martian Medicine 102, where we discuss some more risks from the article “Red risks for a journey to the red planet”. So, let’s just jump into it! The next risk we are going to talk about is Spaceflight-Associated Neuro-ocular Syndrome or SANS.  Wendy: Yes, so this used to be called Vision Impairment Intracranial Pressure because the syndrome affects astronauts' eyes and vision and can appear like idiopathic intracranial hypertension. But the name changed to SANS because is not associated with the classic symptoms of increased intracranial pressure in idiopathic intracranial hypertension such as severe headaches, transient vision obscurations, double vision, and pulsatile tinnitus. Also, it has never induced vision changes that meet the definiti on of vision impairment, as defined by the National Eye Institute. Its name change also reflects that the syndrome can affect the CNS well beyond the retina and optic nerve. Arreaza: Let’s talk about SANS some more. SANS presents with an array of signs including edema of the optic disc and retinal nerve fiber, and what else?Wendy: Edema of chorioretinal folds, globe flattening, and refractive error shifts. Flight duration is thought to play a role in the pathogenesis of SANS, as nearly all cases have been diagnosed during or immediately after long-duration spaceflight such as missions of 30 days duration or longer. But signs have been discovered as early as mission day 10. SANS has been studied in ISS crewmembers who are tested with optical coherence tomography (OCT), retinal imaging, visual acuity, a vision symptom questionnaire, Amsler grid, and ocular ultrasound.Arreaza: About 69% of the US crewmembers on the ISS experience an increase in retinal thickness in at least one eye, indicating the presence of optic disc edema. This can cause an astronaut to experience blind spots and reduced visual function. Fortunately, to date, blind spots are uncommon and have not had an impact on mission performance.Wendy: And chorioretinal folds if severe enough and located near the fovea, an astronaut can experience visual distortions or reduced visual acuity that cannot be corrected with glasses or contact lenses. Fortunately, and despite a prevalence of 15–20% in long-duration crewmembers, chorioretinal folds have not yet impacted astronauts’ visual performance during or after a mission.  Arreaza: A change in your glasses prescription is due to a change in the distance between the cornea and the fovea, and it occurs in about 16% of crewmembers during long-duration spaceflight. This risk is reduced by giving crewmembers with several pairs of “Space Anticipation Glasses” (or contact lenses). The crewmember can then select the appropriate lenses to correct visual acuity. Wendy: From a longer-term perspective, SANS presents two main risks to crewmembers: optic disc edema and chorioretinal folds. It is unknown if a multi-year spaceflight like that to Mars will be associated with a higher prevalence, duration, and/or severity of optic disc edema compared to what has been experienced onboard the ISS. Since the retina and optic nerve are part of the CNS, if optic disc edema is severe enough, the crewmember risks a permanent loss of optic nerve and retinal nerve fiber tissue and thus, a permanent loss of visual function. But again, no astronaut has experienced SANS-related permanent vision loss and choroidal folds usually improved post-flight in affected crewmembers. Arreaza: It is important to understand the pathogenesis of SANS. In microgravity, fluid can distribute uniformly. The fluid that normally pools in your legs due to gravity can now move to your head and cause congestion of the cerebral veins. The pathophysiology of SANS is that CSF outflow can be blocked, which increases intracranial pressure. Wendy: There can be confounding variables such as exercise, high-sodium dietary intake, and high carbon dioxide levels. It is difficult to know much about SANS because there are not many crewmembers who have completed long-duration spaceflight. There is now enough evidence to state that SANS is not a male-only syndrome. Optical Coherence Tomography (OCT) has been used on the ISS since 2013, and it has allowed NASA to build a database of retinal and optic nerve images to understand SANS better. Research from this has shown that most long-duration astronauts present with some level of optic disc edema.Arreaza: Now all NASA crewmembers receive pre- and post-flight MRIs of the brain. There is evidence that brain changes structure with longer space flights. For example, the ventricles of the brain enlarge with 2–3 mL of CSF in astronauts. Luckily, there has been no cognitive problems with this. Like with most space health concerns, more research is needed. Wendy: In summary, SANS is a red risk and top priority to NASA and the human research program. The main concern with SANS is optic disc edema because it could lead to permanent vision impairment. And choroidal folds are also concerning for both short- and long-term flights. But for now, loss of visual acuity is successfully combatted with glasses. Certainly, the more astronauts and flights we take, the more we will learn about SANS.Wendy: Sorry we took so long on SANS, it’s probably one of my favorites of all the red risk. Now let’s move onto the red risk that includes behavioral health and performance. Future long duration mission in which you are in an isolated and confined space such as a space craft surrounded by an inhospitable environment which humans are not meant to survive could be a problem for the crew’s behavioral and mental health. Arreaza: This could affect the astronauts and their ability to complete their mission. Typically, astronauts enjoy space and report it is a positive experience. But psychological changes from being in space for a long time will likely be even more challenging. Wendy: In the past, astronauts have reported ‘hostile’ and ‘irritable’ crew and symptoms of depression. Arreaza: Stressors to the ISS include long work hours and high workload, and the discomfort of space motion sickness. No one likes vomiting.  Wendy: Being on the ISS, you are close to Earth, and it is easy to communicate with family and friends when needed. Going to Mars there will be communication delay and will make support more difficult. Astronauts on the ISS also have routinely received care packages, which will also not be available to boost morale. Crew members can also change by swapping out astronauts over a certain period, but the crew to Mars will also not have this ability to work with new people.  Arreaza: There are simulation projects to test human resilience. NASA does these kinds of testing at the Johnson Space Center. There is also research in Antarctica that has shown decreased mood and increased stress for scientists in extreme environments. There is also the Mars 500 mission.  Wendy: Yes, the Mars 500 mission was where a crew of 6 went into isolation in Moscow for 520 days to simulate a trip to Mars. The astronauts had to complete behavioral questionnaires weekly. One of the six reported depressive symptoms based on the Beck Depression Inventory. Two crew members who had the highest ratings of stress and exhaustion, also reported conflicts and sleep difficulties. Two crew members reported no adverse behavioral symptoms during the mission.Wendy: So, I believe we’re done. We’ve covered Radiation, SANS, and behavioral health. I know this topic is probably unique for qWeek, but a lot of what we learn medically from our time in space does have applications to us on Earth. As a medical student advice, I have gotten from others in the field is pursue what you’re passionate about. Aerospace medicine is a growing field for clinicians from all specialties, so there’s no golden path to take. If you are interested more in this field, I highly recommend joining relevant associations specifically AsMA and AMRSO. And if you ever want to discuss aerospace medicine further, feel free to reach out to me at my Ross email!______________________Conclusion: Now we conclude episode number 151, “Martian Medicine 102.” Future Dr. Collins explained that ocular issues are a potential problem when astronauts go to Mars, including Spaceflight-Associated Neuro-ocular Syndrome and vision impairments that would require changes in glass prescription, so, don’t forget to take extra pairs of glasses when you go to the red planet. Dr. Arreaza also joined the conversation by talking about the mental health challenges that many astronauts may face as they embark on a long trip to Mars in a secluded spacecraft. We look forward to more information on Martian Medicine as primary care on Mars may look surprisingly similar to primary care on Earth.This week we thank Hector Arreaza and Wendy Collins. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Patel, Z.S., Brunstetter, T.J., Tarver, W.J. et al. Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. npj Microgravity 6, 33 (2020). https://doi.org/10.1038/s41526-020-00124-6Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022, from https://freemusicarchive.org/music/Scott_Holmes/. 

Episode 150: Re-update on COVID Vaccines and Cervical CancerCOVID vaccines have been updated (again). The bivalent m-RNA COVID-19 vaccines are no longer authorized in the US. Sabrina explains that the monovalent COVID-19 vaccines will be available soon to target XBB lineage and more. Future Dr. Rodriguez explains the USPSTF cervical cancer screening guidelines. Dr. Arreaza adds comments and insight.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Celebrating our episode 150.Written by Hector Arreaza, MD.In our previous episode, we gave you an update on COVID-19 vaccines, but we need to give a new update. This is the risk you take when you try to become a news agency instead of an educational podcast, so you need to keep giving updates, and we’ll tell you about the newest change in COVID-19 vaccines in a few minutes. This is episode number 150! And I wanted to take a moment to celebrate this milestone. Our first episode was released a few days before the lockdown for COVID-19 on March 3, 2020. Those were gloomy days. I was excited about having a weekly podcast, but I also was overwhelmed by COVID-19. I remember considering putting a hold on the podcast, but I decided to continue. We had a few episodes about COVID-19 and, as expected for a novel disease, we made some mistakes. For example, we gave the wrong recommendations to not wear a mask at the very beginning of the lockdown, but that was the initial recommendation. However, I got to accentuate the positive, I’m proud that we were probably the first place to report hiccups as a symptom of COVID. Soon I realized it would be impossible to keep up with the daily changes in recommendations and updates on COVID, so we focused on other topics, and it has been a great experience so far. This podcast was created for the Rio Bravo residents, and thankfully the medical students have become the main collaborators of this program. I have enjoyed every second I have spent with all our guests, including residents, nurses, medical assistants, specialists, scientists, and of course medical students. I feel very fortunate to have reviewed many relevant topics of family medicine with you. A colleague once mentioned to me that I may run out of topics, but I think it is impossible to run out of topics in family medicine, don’t you think? So, I’m hoping to continue bringing to you brief discussions and pearls of knowledge every week. Now, let’s listen to Sabrina.Re-update on COVID-19 Vaccines.Written by Sabrina Hawatmeh, MSIII, Ross University School of Medicine.Hi, my name is Sabrina Hawatmeh, I’m a 3rd-year medical student from Ross University School of Medicine. I’m so excited to be here today, huge thank you to Dr. Arreaza for having me here today! As mentioned by Dr. Arreaza, during our episode 149 we gave you an update on COVID-19 vaccines and now today it’s time for a new update. Most recently, Pfizer/BioNTech and Moderna have updated their vaccines to target specific strains of the virus, and the American Academy of Family Physicians has given its approval to federal actions allowing the use of these updated vaccines for the Fall/Winter of 2023. The decision follows FDA approval for these vaccines for children and adults aged 12 and older, as well as CDC recommendation of emergency use authorization for children aged 6 months to 11 years. The AAFP's Board Chair, Sterling Ransone, M.D., accepted the recommendation to approve these actions as of September 14th, 2023. The vaccines may be available soon for administration. Bivalent vaccines were the most recent formula administered for immunization. Studies had shown that there was continued protection against circulating sublineages of Omicron and XBB.1.5. However, the vaccine effectiveness against Omicron decreases over time. Neutralizing antibody titers against XBB sublineages via bivalent vaccines are lower compared to titers induced by the matched BA.4/BA.5 sublineage. So, it makes sense that all this data suggested that vaccine modification be directed toward more closely matched strain composition to current circulating sublineages. I also think it's worth noting that the original version of Omicron is no longer circulating—neither is the original strain of the SARS-CoV-2 virus. For that reason, updated vaccines were created by Moderna and Pfizer/BioNTech, so the bivalent vaccines are no longer authorized for use in the United States. The updated vaccine recommendations include eligibility criteria for different age groups, regardless of previous vaccination status, and specify the number of doses needed. The CDC has also updated its vaccine recommendations, especially for moderately or severely immunocompromised individuals. The new vaccines are monovalent mRNA vaccines, designed to protect against omicron subvariant, XBB 1.5. While the subvariant XBB.1.5 is the target of the vaccines, the expectation is that they will offer immunization against multiple current strains. (XXB lineage, EG.5.1 (Eris), Fl.1.5.1 (Fornax), BA.2.86). Moderna (randomized controlled trial of 101 individuals) and Pfizer (mouse studies) evidence suggests that the vaccines will also serve to protect against the new mutated subvariant that has recently sparked some concern, BA.2.86. As a reminder, FDA granted emergency use authorization for Novavax COVID-19 vaccine, Adjuvant in July 2022 for the prevention of COVID-19 pneumonia in patients aged 12 and older. Now the updated Novavax formula for 2023-2024 (targeting the XBB strain) was authorized by CDC on September 12, 2023, but it is still under review by the U.S. FDA for emergency use authorization for individuals aged 12 and older. When authorized, Novavax's protein-based vaccine will be the only non-mRNA COVID vaccine available in the U.S. These updated vaccines are expected to be covered by most public and private insurance plans, but concerns have been raised about uninsured individuals having to pay out of pocket for the vaccines, which cost $120 to $130. The AAFP urged the government to ensure equitable access and financial support for primary care practices offering these vaccines.Cervical Cancer Screening Guidelines. Written by Adriana Rogriguez, MSIV, Ross University School of Medicine.Arreaza: Cervical canceris the 3rd most common gynecological cancer in the US. For 2023, the American Cancer Society estimates that about 13,000 new cases of cervical cancer will be diagnosed, and more than 4,000 women will die this year. Cervical cancer was once one of the most fatal types of cancer in women, but the mortality rate has been significantly decreased with the increased use of pap smears and the HPV test. Adriana: Another fun fact is that cervical cancer is the only cancer preventable by a vaccine—the HPV vaccine.Arreaza: Why is cervical cancer screening important?Adriana: Cervical Cancer screening is very important as it reduces mortality due to cervical disease. Intervention at early stages reduces the development of squamous cell carcinoma or adenocarcinoma of the cervix due to HPV. In fact, studies have shown that in resource-poor settings, one cervical screening reduces the incidence of cervical cancer by up to 50%. Arreaza: What would prevent a patient from wanting to get a Pap smear?Adriana: Many things can and do deter a patient from obtaining their cervical cancer screening. Patient discomfort and the psychosocial consequences of performing these screenings such as anxiety should be taken into consideration. Personal example. Also, a patient may be concerned about the costs, the effects of false-positive results, the risks of treatment during pregnancy (ex., increased risk/o 2nd-trimester pregnancy loss, PPROM, preterm delivery, perinatal mortality). Arreaza: We should mention the cultural implications of a pap smear in a 21-year-old who is considered a “virgin”. Some cultures try to preserve the hymen intact as a sign of purity. You can address this concern with your patients and explain that a hymen is not always present, it may be easily ripped by sports, biking, tampon use, and more. A small speculum may be used for your patients who have never been sexually active at age 21. Arreaza: We perform screening BEFORE we diagnose a disease. The age of diagnosis of cervical cancer is age 50, most patients fall between 35 and 45 years old. How can we determine who is at risk and needs a pap smear? Adriana: When looking at cervical screening guidelines and recommendations, we are looking at the patient who is: At average risk for cervical disease – a patient who is asymptomatic, immunocompetent, and has had all previous cervical cancer screening results within normal limit.At sufficiently low-risk for cervical disease and can return to routine age-based screening: >25 yo with LSIL, following colposcopy w/o CIN 2 or worse AND following consecutive co-testing results (-) x3.Arreaza: Those are the patients we are going to screen for cervical cancer. Let’s start with the basics of the United States Preventive Services Task Force (USPSTF) guideline. We start screening at age 21 regardless of sexual activity.Adriana: Yes Arreaza: Actually, the treatment of CIN2 and CIN3 before age 21 may increase the risk of adverse pregnancy outcomes.Adriana: 21-29: begin at age 21, cervical cytology Q3yrs.USPSTF recommends Cytology > HPV testing (primary or co-testing) because of higher rates of false-positives from higher rates of transient infection in this particular age-group; it is not adjusted for HPV-vaccination status.Arreaza: Tell me about patients older than 30.Adriana: 30-65: Primary HPV testing (FDA approved test) Q5yrs, Co-testing (Pap AND HPV) Q5yrs, or Pap test alone Q3yrs. Here we have options, and the USPSTF does not recommend one method over the other regardless of vaccination status and still recommends screening even if the patient reports sexual abstinence. Arreaza: The most common method in our clinic is: Pap + HPV (contesting) every 5 years after age 30. What about the grandmas older than 65?Adriana: >65: Both USPSTF and ACS suggest discontinuing screening in average-risk patients if she has had adequate screening with NORMAL results. Discontinuing screening predicated on meeting both following criteria: No history of CIN 2 or higher for the past 25 yrs.Adequate prior screening: 2 consecutive (-) primary HPV tests or co-testing w/n past 10 yrs, most recent w/n past 5 yrs.3 consecutive (-) Pap tests w/n past 10 yrs, most recent w/n 3 yrs. If results of screening w/n prior 10 yrs is not known à not adequate à Screen.Arreaza: The guidelines also recommend keeping routine screening for at least 20 years after spontaneous regression or appropriate management of a precancerous lesion, even if the patient turns 65 years of age.Adriana: Data for stopping age for cervical cancer screening are limited. Other countries use older age to stop screening. For example, Australia has the lowest cervical cancer mortality rate in the world, and their guidelines recommend discontinuing screening at 74 yo. With that said, some clinicians continue to offer screening through age 74 for those w/ life expectancy of at least 10 yrs. Conversely, screening can also be d/c’d for patients w/ limited life expectancy.Arreaza: Who does not get screened?Adriana: Women before age 21 or older than 65 who have had adequate screenings, as we just described a few moments ago, and Patients s/p hysterectomy for benign disease. Arreaza: You mentioned patients s/p hysterectomy receive different screening.Adriana: Yes, they do! If a Patient has a hysterectomy for benign dz: Routine screening not performed. However, there is a caveat. If they have HIV-related disease progression (for example, viral count increases, or CD4 decreases), then Q1yr screening w/ Pap test or co-test and pelvic exam is indicated. Then if a Patient had a hysterectomy because of Invasive cervical cancer their surveillance is different. They receive PET/CT imaging 3-6mos post-treatment; H&P Q6-12 mos x5 years w/ cervicovaginal cytology Qyearly if no radiation therapy, or w/o cervicovaginal cytology if previously received radiation therapy.Arreaza: You mentioned that the guidelines earlier were for patients at average risk for cervical disease. What would make a Patient high risk?Adriana: High risk patients include patients with immunosuppression, ie., a person whose immune system cannot fight off hrHPV, and is at higher risk of developing squamous cell carcinoma or adenocarcinoma of the cervix later on. Also at high risk are patients with in-utero exposure to di-ethyl-stilbestrol (DES).Arreaza: Let’s review the recommendation for patients who are immunosuppressed.Adriana: HIV Patients and Immunosuppressed patients w/o HIV: Receive both screening and colposcopy at the time of diagnosis, and between 21-29 yo are screened with cervical cytology every year x3, if normal perform cytology every 3 years. >30yo cytology or co-testing. Primary HPV testing is not approved in Patients w/ HIV. Subsequent screening: continues through lifetime and does not end at 65 yo.Arreaza: Normal: Sample was adequate for evaluation and the report may state: Negative for intraepithelial lesion. What is considered an abnormal result?Adriana: Results are abnormal if any of the following occur: Pap test satisfactory for evaluation but limited Pap test unsatisfactory ABNL HPV testing but NL Pap testing ABNL HPV testing w/o Pap test  ABNL Pap results (ASCUS, LSIL, HSIL, Atypical and malignant glandular cells) Cervical cancerThese are all a wide array of results and considered abnormal, but receive different surveillance and or treatments. Arreaza: So, what happens if the average Patient has a history of abnormal cervical cancer screenings? Adriana: These patients are now managed w/ active surveillance, not screening. It gets a little complicated and out of the scope of this episode.Arreaza: At this point, I recommend to our listeners to download the ASCCP app. Adriana: Conclusion: Pap smear is one the strongest arsenals in the physicians’ toolbox. Start screening at age 21, until 65 years old._________________________Conclusion: Now we conclude episode number 150, “Re-update on COVID Vaccines and Cervical Cancer.” Sabrina gave a very good summary of the updated COVID vaccines, and we are hoping to have good coverage for the most common strains. Make sure you get your updated vaccine as it becomes available soon. Future Dr. Rodriguez explained that pap smears and HPV tests are some of the most powerful tools we have to prevent cervical cancer. Dr. Arreaza added some ideas about how to overcome the cultural barrier to start screening at the age of 21.Today we celebrate our episode 150! We look forward to many more episodes in the future! This week we thank Hector Arreaza, Sabrina Hawatmeh, and Adriana Rodriguez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Feldman, MD, MPH, Sarah, et al. “Screening for cervical cancer in resource-rich settings.” UpToDate, Aug 28, 2023. https://www.uptodate.com/contents/screening-for-cervical-cancer-in-resource-rich-settingsRecommendation: Cervical Cancer: Screening, United States Preventive Services Taskforce, August 21, 2012. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cervical-cancer-screeningRoyalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022, from https://freemusicarchive.org/music/Scott_Holmes/. 

Episode 149: COVID Vaccines Update [Historic episode].  Future Dr. Williams presented an update on COVID-19 vaccines. This update is only for immunocompetent individuals, and it was recorded on August 24, 2023. Dr. Arreaza added comments and insight.  Written by John Williams, MS4, Ross University School of Medicine. Editing by Hector Arreaza, M.D.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Currently, there are two types of vaccines that have been approved by the FDA:Moderna and Pfizer developed mRNA vaccines.Novavax developed a lesser-known protein subunit vaccine.As of May 6, 2023, the vaccine developed by Johnson & Johnson has expired and is not available in the U.S.Novavax: This vaccine contains pieces (proteins) of the virus that causes COVID-19, the spike protein plus an adjuvant. It works by activating the immune system against the spike protein, so it will be ready to fight the actual virus when you get infected. Regardless of vaccine type, the shots are administered in the upper arm and have been demonstrated, for most people, to be safe and effective. There have now been hundreds of million vaccines administered in the US alone and the effectiveness of the vaccine to reduce the risks of severe illness, hospitalization, and death has been well documented. The most common side effects consist of mild to moderate cases of fever, chills, headache, and tiredness that are self-resolving.What is new about COVID-19 Vaccines?The updated vaccine is known as “bivalent”. This term is important because it refers to the vaccine’s ability to confer protection against both the original COVID-19 virus as well as new variants Omicron BA.4 and BA.5. Rollout of the updated vaccine began in September 2022 for those aged 12 years and older and became widespread in March 2023 with approval granted for use in children aged 6 months – 4 years. Selected individuals over age 65 or those who are immunocompromised may receive additional doses to provide comparable and safe protection. The receipt of the updated vaccine supersedes any previous doses and provides coverage against the most recent known variants determined to be either most widespread or that have been projected to be more prevalent.Children aged 6 months – 4 years who received the original Pfizer vaccineThose who received either 2 or 3 doses of the original vaccine should receive 1 dose of the updated vaccine.Those who received 1 dose of the original vaccine should receive 2 doses of the updated vaccine.You are considered up to date if you have received 3 vaccine doses, including at least 1 updated dose.Children aged 5 years who received the original Pfizer vaccineThose who received 1+ doses of the original vaccine should receive 1 dose of the updated vaccine.You are considered up to date if you have received at least 1 updated dose.Children aged 6 months – 4 years who received the original Moderna vaccineThose who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.Children aged 5 years who received the original Moderna vaccineThose who received either 2 or 1 dose(s) of the original vaccine should get 1 updated vaccine.Unvaccinated children 6 m-4 years should receive the new bivalent vaccine, 2 doses ofModerna or 3 doses of Pfizer, but if you are 5 years old and unvaccinated, you will receive 1 dose of Pfizer or 2 doses of Moderna.For 6-11 yo patients who have been vaccinated with 1 or more doses of monovalent (Moderna or Pfizer) will receive 1 dose of Bivalent Moderna or Pfizer. If you already received 2 monovalent doses and 1 bivalent dose, you are done, no more vaccines are needed. If you have not received any COVID-19 vaccine and you are in this age group (6-11 yo), you only need 1 bivalent dose, and you are done.>12 yo and Adults. If you received 1 or more doses of monovalent or if you are not vaccinated, you need 1 dose of bivalent (Pfizer or Moderna). If you already had 2 doses of monovalent and 1 dose of bivalent, you are done!An FDA advisory committee convened on June 15, 2023, to discern the importance for additional updates to the most recent COVID-19 vaccine series. It was determined that the latest circulating variant currently making rounds is from the Omicron group known as XBB. The committee decided it is prudent to proceed with a preference for the XBB 1.5 variant. The updated vaccine will be a monovalent version available in the Fall of 2023. As with the previous version, the FDA will provide strict oversight and safety monitoring of the vaccine._______________________________Conclusion: Now we conclude episode number 149, “COVID Vaccines Updates.” Future Dr. Williams explained that the bivalent COVID vaccines are currently recommended for unvaccinated patients, or for those who were previously vaccinated with monovalent vaccines. This episode focused on patients who are NOT immunocompromised. We encourage our audience to check the CDC website for recommendations about patients who are immunocompromised.As a clarification, our sub-intern, John Williams, has a great sense of humor and he claimed to be the composer of the music for many famous Hollywood movies. We don’t doubt his musical talent, but we must make clear that it was a joke! This week we thank Hector Arreaza and John Williams. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Tin, Alexander, New COVID vaccine and booster shots for this fall to be available by end of September, CBS Texas, published online on August 9, 2023. https://www.cbsnews.com/texas/news/covid-vaccine-booster-xbb-variants-september-2023/, accessed on September 7/, 2023.Center for Disease Control and Prevention, Overview of COVID-19 Vaccines, updated May 23, 2023, https://www.cdc.gov/coronavirus/2019-ncov/vaccines/different-vaccines/overview-COVID-19-vaccines.html, accessed on September 7, 2023.Updated COVID-19 Vaccines for Use in the United States Beginning in Fall 2023, United States Food and Drug Administration. https://www.fda.gov/vaccines-blood-biologics/updated-covid-19-vaccines-use-united-states-beginning-fall-2023, accessed on September 7, 2023.Royalty-free music used for this episode: Gushito - Latin Chill. Downloaded on July 29, 2023, from https://www.videvo.net/  

Episode 148: Leg CrampsFuture Dr. Weller explains the pathophysiology, management, and prevention of leg cramps. Hector Arreaza adds comments and anecdotes about leg cramps.  Written by Olivia Weller, MS4, American University of the Caribbean School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition: Known also as “Charlie horses,” leg cramps are defined as recurrent, painful, involuntary muscle contractions. They can last anywhere from seconds to several minutes, with an average of nine minutes per episode. They are usually nocturnal and thus may be associated with secondary insomnia. Location: A muscle cramp can happen in any muscle in the body, but they occur most commonly in the posterior calf muscles, but they can also involve the thighs or feet. They are more common in women than men and the risk increases with age.Although they are experienced by 7% of children and up to 60% of adults, the exact mechanism remains unknown and there is no definitive treatment at this time. PathophysiologyThere is one leading hypothesis for nocturnal cramps that occur in the posterior calf muscles, and it is related to your sleeping position. When you are laying down in bed your toes are pointed which causes passive plantar flexion while the muscle fibers are shortened maximally. This causes uninhibited nerve stimulation with high-frequency involuntary discharge from lower motor neurons, which causes cramping. Another possible etiology is nerve damage because neurologic conditions such as Parkinson’s disease are associated with a higher-than-normal incidence of cramps. Peripheral neuropathy, or damage to the connection between motor nerves and the brain can lead to hyperactive nerves when they are not being properly regulated. Thus, diabetes mellitus is a major risk factor for nocturnal cramps due to the high blood sugar levels damaging the small blood vessels which supply the muscles. Decreased blood flow has also been attributed as a cause of leg cramps. People with diseases that affect their vasculature, such as varicose veins or peripheral arterial disease also have a higher incidence of leg cramps. Decreased blood flow to the muscles means less delivery of oxygen and nutrients to the muscles which makes them more susceptible to fatigue. Muscle overuse is one of the dominant explanations for cramping. This can be related to doing too much high-intensity exercise without adequate stretching before and after. Pregnant women have added weight which puts extra strain on the muscles, along with sitting or standing for long periods of time, poor posture and flat feet. Notably, when we age, our tendons naturally shorten and they cannot work as hard, or as quickly which makes them more susceptible to overuse. Additionally, there are mineral deficiencies such as magnesium and potassium or decreased levels of B and D vitamins. With this in mind, people with renal failure that are on hemodialysis have an increased risk of nocturnal leg cramps. And finally, we have medications, some of which are related to mineral deficiencies. The main contributors are statins, diuretics, conjugated estrogens, gabapentin or pregabalin, Zolpidem, clonazepam, albuterol, fluoxetine, sertraline, raloxifene, and teriparatide (analog for parathyroid hormone). Management and preventionThere is no magic treatment to make them go away immediately, however, there are different remedies you can try to help facilitate. My Grandma told me about an old wives' tale, that if you put a bar of soap in your bed at your feet while you sleep, you won’t get cramps at night. Maybe it works by the placebo effect, maybe there's a mechanism going on there I don't understand who knows, I’ll have to do a study on it. If you get them very often, you can keep a foam roller or a heating pad next to your bed in preparation for when they come. Stretching the muscle is known to be very effective, as well as applying heat or ice to the affected area. You can also try massaging the muscle with your hands or getting out of bed to stand or walk around. Elevating the leg while laying down in bed can also be beneficial. In terms of prevention, you can try out different sleeping positions to see if one works better for you. If you usually sleep on your back, you can stick a pillow under your feet to help keep your toes pointed upward. Or, if you sleep on your stomach you can try to keep your feet hanging off the bed. Another tip is loosening the sheets or blankets around your feet. Daily stretching, especially before and after exercise as well as before bed is useful. Make sure to exercise, stay hydrated, and limit your alcohol and caffeine consumption. You also want to wear supportive shoes or use orthotic inserts in your shoes, especially if you spend lots of time on your feet during the day. Medications/supplements: Since various deficiencies can cause cramps, one way to prevent them is to take supplements such as magnesium, vitamin D, and B12 complex. And as a last resort, you can try medications. Calcium channel blockers such as diltiazem or verapamil have been used, and muscle relaxants including Orphenadrine (Norflex®) and Carisoprodol (Soma®). Gabapentin is an anticonvulsant commonly used as a neuropathic pain medication; this used to be used to treat leg cramps but later it was found that they can actually increase the frequency of muscle cramps so they are no longer used. Quinine was also used for many years to treat leg cramps; however, it is no longer recommended because of drug interactions and serious hematologic effects such as immune thrombocytopenic purpura (ITP) and hemolytic uremic syndrome (HUS). Summary: Leg cramps are common, the pathophysiology is unclear, but may be related to problems with blood flow, the nervous system, sleeping position, and muscle overuse. Treatment includes nonpharmacologic therapies such as changes in sleeping position, heat, and massaging; and medications/supplements that may be useful include Carisoprodol (Soma®), diltiazem, gabapentin (Neurontin), magnesium, orphenadrine (Norflex®), verapamil, and vitamin B12 complex.____________________________Conclusion: Now we conclude episode number 148, “Leg Cramps.” Future Dr. Weller explained that the etiology of leg cramps is multifactorial. Some theories about why leg cramps happen include poor circulation, muscle overuse, dysfunctions in the nervous and musculoskeletal systems, electrolyte imbalances, mineral deficiencies, and more. Some therapies were discussed, including changes in position while sleeping, massage, heat pads, and medications such as calcium channel blockers, muscle relaxants, and supplements of magnesium and Vitamin B12. Gabapentin is a medication that can cause leg cramps, but some sources recommend it as a treatment as well. This week we thank Hector Arreaza and Olivia Weller. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Leg Cramps. Cleveland Clinic. (2023, May 6). https://my.clevelandclinic.org/health/diseases/14170-leg-crampsAllen, R. E., & Kirby, K. A. (2012, August 15). Nocturnal leg cramps. American Family Physician. https://www.aafp.org/pubs/afp/issues/2012/0815/p350.htmlMayo Foundation for Medical Education and Research. (2023, March 2). Night leg cramps. Mayo Clinic. https://www.mayoclinic.org/symptoms/night-leg-cramps/basics/definition/sym-20050813Royalty-free music used for this episode: Simon Pettersson - Good Vibes_Sky's The Limit_Main. Downloaded on July 29, 2023, from https://www.videvo.net/ 

Episode 147: Routine Prenatal CareWritten by Elika Salimi, MSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments and editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice._____________________Elika: So, we’re going to talk about some general principles of prenatal care and some of the most important diagnostic methods that we mainly use for taking care of pregnant women. I will forewarn you that there will be a ton of details in this talk, and I do recommend possibly taking notes as things can get easily confusing. This way you can have something to refer back to whenever you have a pregnant patient of your own.Arreaza: You can also download the episode notes from our website.Elika - So your patient is pregnant and she comes to you for care. How do we go about it? Well, this is assuming she had it at home urine pregnancy positive test and we got a blood hCG on her and everything’s good and we know she’s pregnant. Ok so now what happens next?Arreaza – We need to confirm the patient wants to keep the pregnancy.Elika - First, we’re going to talk about the frequency of the check-ups. In this case, we are talking about a situation where the mother is coming to her appointments as she was supposed to but we all know that sometimes that doesn’t happen if everything is going as it is supposed to then typically we get the initial examination at about 10 weeks of gestation and then until the 28th week there should be monthly visits, then from the 28th through the 36th there should be biweekly visits, and from the 36th week until birth, the visits are every week.Areaza – What´s next?Elika - Now I’d like to note that during the prenatal period, informed consent is very important and it should be obtained during this time because you want to prevent and manage any ethical conflicts that might exist between the mother and possibly the healthcare providers because we all know that any pregnancy can become high-risk at some point and pregnant individuals should be informed about the potential need for a c-section for example and be encouraged to discuss any concerns ahead of time. Elika - Now while we’re talking about ethics, if the doctor finds him/ or herself in a situation where the patient is asking for something that the Dr does not feel comfortable with such as a certain type of treatment or a certain method of delivery or if they’re, let’s say, desiring an abortion and the doctor doesn’t do abortions, then in this case you would refer the patient to a physician that is comfortable with the patient’s desired outcome or treatment. And this is perfectly legal and fine just as long as you help the patient find somebody else. Arreaza – Abortion is legal in most states, but check your local regulations.Elika - So as mentioned earlier, the initial visit occurs at about 10 weeks of gestation. We start with checking their personal and family history and finding out about any previous pregnancies including at what GA baby born and weight if they know, any complications, gestational diabetes or preeclampsia, any history of postpartum hemorrhage requiring blood transfusion, any abortions (if present at what GA), and the method of deliveries, whether it was vaginal or a cesarean and what kind of C-section they had done. These are very important for you to obtain from your patient. You will also assess for depression and domestic partner violence.Arreaza – In California, we have a wonderful service called CPSP: Comprehensive Perinatal Services Program. What comes next? Elika - Upon receiving the history, we will do the gynecological examination and send in some samples. We will also send her to do some lab work. Now what do those labs entail? Well, we are going to get a CBC such as screening for anemia, we will also do TSH but only in people who have possible signs of thyroid disorder so not everybody needs to get this. And, we are going to send for a blood typing to find out about their ABO group and the Rhesus status. We will also obtain a urine analysis to screen for proteinuria and asymptomatic bacteriuria because in pregnancy, unlike outside of pregnancy, you do need to treat asymptomatic bacteriuria. We will also ensure that the mother is on prenatal vitamins, so folic acid, if not already, and iron, if indicated, and vitamin B6 if the patient has signs of nausea or hyperemesis gravidarum and this can be combined with doxylamine. Usually, pregnant women don’t get a glucose screening test at the first visit unless let’s say they have high risk of diabetes or they there was glucose in the urine. Arreaza – I like the topic of diabetes in pregnancy. So, in a high-risk population, we want to make sure a pregnant patient does not have diabetes, or pregestational diabetes.Elika - We will also screen for STI’s including HIV, syphilis, hepatitis B, Hep C, and we also check for gonorrhea and chlamydia (pap) screening particularly in those under 25, or over 25 with high risk of infection. We will also test for rubella and varicella. Some places also order a QuantiFERON gold for tuberculosis. There are certain women that have indications for third-trimester screening for STI’s on top of the ones that they already got in their first trimester. Those include chlamydia, gonorrhea, HIV, syphilis, and Hep B, and C but each of those have its own indications so for the purposes of time I will let you look that up on your own.Arreaza – Summary: Physical exam and labs to rule out preexisting conditions that may interfere with pregnancy, either infectious or metabolic, to mention some diseases. Elika - And finally, we will do an ultrasound assessment to get a more accurate reading of the fetus’s gestational age.Arreaza – What comes after the first trimester?Elika- So like I mentioned they’re going to need to be following up and some particular things need to be done at specific weeks. So we are going to discuss those. At every follow visit you need to obtain: the patient’s weight, BP and other vitals, fetal heart sounds, the baby’s measurement from the mother’s pubic symphysis up until the fundus of the uterus, as well as a urine analysis to check for any glucose or protein in the urine because we are always concerned of possible preeclampsia or gestational diabetes. Another examination that I should mention is a Doppler ultrasound and this is usually indicated if there is suspected fetal growth restriction or if there’s pregnancy-induced hypertension or if there’s suspected fetal deformities or there is growth discordance in multiple pregnancies.Now we are going to discuss assessing for any abnormalities in the fetus. All pregnant women regardless of age should be offered noninvasive and aneuploidy screening test before 20 weeks of gestation. The 1st trimester combined screening occurs at about 10 to 13 weeks gestation, where we can order some blood tests for the mom such as the amount of hCG in maternal serum, as well as PAPP-A, on top of nuchal translucency that will see on the ultrasound. There is also the triple screen at 15-20 weeks which consists of ordering hCG, alpha-fetoprotein aka AFP, and estriol then there’s also the quad screen test at 15-22 weeks gestation that consists of hCG, AFP, Estriol and Inhibin A. We also have the cell free fetal DNA testing that can occur after 10 weeks gestation at which the fetal DNA is isolated from the maternal blood specimen for genetic testing and this one actually happens to be the most sensitive and specific screening test for common fetal aneuploidies, and it is used for secondary screening after the ultrasound.Arreaza – Actually that test is done in all our patients on Medi-Call (cfDNA).Elika - If any of the screening tests are abnormal then we can provide counseling to mothers for more invasive diagnostic tests such as chorionic villus sampling, amniocentesis, and cordocentesis. At that point, you want to refer the patient to perinatology. Finally, in general an anatomical scan occurs ~18-22 weeks. Arreaza – Excellent, we have done the non-invasive genetic screening. What’s next? Elika - Now we are going to talk about what happens in the third trimester specifically and what test you need to order. In the third trimester, you will order a CBC again, particularly at 24 weeks you want to do a repeat hemoglobin. We will also do the indicated repeat STI checks. We are also going to do gestational diabetes screening with the oral glucose test that I briefly mentioned earlier at around 24-28 weeks. This is usually done with a 50g 1 hr glucose tolerance test and if abnormal then a 100g 3 hour glucose test. You will also be repeating the Rh antibody just to make sure that the mother is still Rh negative because at 28 weeks, Rh negative mother should be administered RhoGAM 300 mcg intramuscularly and they need to get it again within 72 hours of delivery. Don’t forget to give a TDAP vaccine at 27 weeks. And at 36 weeks you need to be obtaining a GBS culture (vaginal and rectal) for the patient just to make sure that there is no colonization because if there is then the patient is going to need GBS prophylaxis at admission because colonization by these bacteria can cause chorioamnionitis and neonatal infection such a sepsis. Overall when third trimester approaches you’re going to make sure the plans for delivery have been properly scheduled or discussed with the patient and typically around 34 weeks you also want to check with your patient to see if they desire sterilization and obtain a consent if they will be having a C-section and they want to be sterilized after that. In those not requesting sterilization, it is a good idea to discuss what they want to do after this pregnancy for birth control since it is not safe to get pregnant again for another year. From 36 weeks' gestation, use Leopold maneuvers for assessment of fetal presentation but I'll let you look that up on your own. At this time, you may also use ultrasound as needed to confirm fetal lie and placental position.Patients with maternal conditions such as gestational diabetes or gestational hypertension/pre-eclampsia, or fetal condition such as heart defects or fetal growth restriction need to get biweekly NST/BPP tests at clinic in the third trimester because there is an increased risk of fetal hypoxic injury or death. An NST is basically a non-stress test that measures fetal heart rate reactivity to fetal movements. BPP /biophysical profile is a noninvasive test that evaluates the risk of antenatal fetal death usually after the 28th gestational week and what it consists of is the ultrasound assessment of fetal movement, fetal tone, fetal breathing, and amniotic fluid volume or we can also perform a contractions stress test that basically measures fetal heart rate reactivity in response to uterine contractions. Arreaza – I like talking about obesity. Weight gain is expected during pregnancy. Patients with normal weight are expected to gain 25-35 pounds. Patients with obesity are recommended to gain 11-20 only.Summary: Now I know that this was very extensive talk with a ton of details but if you took notes and refer back to it then I think things will somewhat make more sense and come together that way. The best thing we can do is try to adhere to guidelines to make sure that we don’t miss anything. Sometimes it could be particularly difficult to manage patients that don’t or can’t come to their appointments regularly and you may sometimes have to give them bad news and what not so overall it is not always happy moments we face but the best we can do is try to give them the best care possible to avoid complications and have the patient deliver a healthy baby. Thank you for listening to me once again and hopefully I’ll be back again soon on another talk on an OB/GYN related topic soon. Thank you very much. _____________________Conclusion: Now we conclude episode number 147, “Routine Prenatal Care.” Future Dr. Salimi gave an excellent summary of the care provided during the different trimesters of pregnancy. Remember to collect a detailed history, perform a comprehensive physical exam, and order the labs to rule out pre-existing conditions that could interfere with pregnancy or detect complications early to start timely interventions or refer to a higher level of care. This week we thank Hector Arreaza, Elika Salimi, and Verna Marquez. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:AAP, ACOG. Guidelines for Perinatal Care. American College of Obstetricians and Gynecologists Women's Health Care Physicians; 2017Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014; 89(3): p.199-208. pmid: 24506122.World Health Organization. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. World Health Organization; 2016Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR. Recommendations and Reports. 2021; 70(4): p.1-187. doi: 10.15585/mmwr.rr7004a1Murray ML, Huelsmann G, Koperski N. Essentials of Fetal and Uterine Monitoring. Springer Publishing Company; 2018Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/.

Episode 146: RA vs OA    Future Dr. Magurany explains how to differentiate rheumatoid arthritis from osteoarthritis.  Written by Thomas Magurany, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.1. Etiology: Rheumatoid Arthritis (RA): RA is an autoimmune disease wherein the immune system mistakenly attacks healthy tissues, particularly the synovial joints, usually between the ages of 30-50. Genetic predisposition, environmental factors such as smoking or infections, hormonal imbalances, and lower socioeconomic status have been associated with an increased risk of developing RA(1).Osteoarthritis (OA): OA primarily arises due to mechanical stress on the joints over time. Factors contributing to OA include age, obesity, joint injury or trauma, repetitive joint use or overuse, genetic abnormalities in collagen structure, and metabolic disorders affecting cartilage metabolism (2).The greatest risk factor for the development of OA is age with most patients presenting after 45 years of age. The greatest modifiable risk factor for OA is weight. People with a BMI >30 were found to have a 6.8 times greater risk of developing OA. (3) Primary OA is the most common and is diagnosed in the presence of associated risk factors such as: older age, female gender, obesity, anatomical factors, muscle weakness, and joint injury (occupation/sports activities) in the absence of trauma or disease. Secondary OA occurs alongside a pre-existing joint deformity including trauma or injury, congenital joint disorders, inflammatory arthritis, avascular necrosis, infectious arthritis, Paget disease, osteopetrosis, osteochondritis dissecans, metabolic disorders (hemochromatosis, Wilson’s disease), Ehlers-Danlos syndrome, or Marfan syndrome.2. Pathogenesis:Rheumatoid Arthritis (RA):In some patients, RA is triggered by some sort of environmental factor in a genetically predisposed person. The best example is tobacco use in a patient with HLA-DRB1. The immune response in RA starts at sites distant from the synovial joints, such as the lung, gums, and GI tract. In these tissues, modified proteins are produced by biochemical reactions such as citrullination. (4)In RA, an abnormal immune response leads to chronic inflammation within the synovium lining the joints. The inflammatory cytokines released cause synovitis and lead to the destruction of articular cartilage and bone erosion through pannus formation. Immune cells infiltrate the synovium causing further damage. (4) In summary: formation of antibodies to citrullinated proteins, these antibodies begin attacking wrong tissues.Osteoarthritis (OA):The primary pathological feature of OA is the degeneration of articular cartilage that cushions the joints causing surface irregularity, and focal erosions. These changes progress down the bone and eventually involve the entire joint surface. Mechanical stress triggers chondrocyte dysfunction, leading to an imbalance between cartilage synthesis and degradation that cause cartilage outgrowths that ossify and form osteophytes. This results in the release of enzymes that degrade the extracellular matrix, leading to progressive cartilage loss. As more of the collagen matrix is damaged, chondrocytes undergo apoptosis. Improperly mineralized collagen causes subchondral bone thickening; in advanced disease, bone cysts infrequently occur (5). In summary: Osteophytes formation and cartilage loss.3. Clinical Presentation:Rheumatoid Arthritis (RA):The most common and predominant symptoms include joint pain and swelling, usually starting insidiously over a period of weeks to months. RA typically affects multiple joints symmetrically, commonly involving small joints of the hands, wrists, feet and progresses to involve proximal joints if left untreated. Morning stiffness lasting more than an hour is a characteristic feature. The affected joint will be painful if pressure is applied to the joint or on movement with or without joint swelling. Synovial thickening with a "boggy" feel on palpation will be noted. The classical physical findings of ulnar deviation, metacarpophalangeal joint subluxation, swan neck deformity, Boutonniere deformity, and the "bowstring" sign (prominent and tight tendons on the dorsum of the hand) are seen in advanced chronic disease. (4) Around ¼ of patients with RA may present with rheumatoid noduleswhich are well demarcated, flesh-colored subcutaneous lumps. They are usually described as being doughy or firm and are not typically tender unless they are inflamed. They are usually found on areas susceptible to repeated trauma or pressure and include the elbows, fingers and forearms. Osteoarthritis (OA):OA primarily affects weight-bearing joints such as knees, hips, spine, and hands. Symptoms include joint pain aggravated by activity and relieved with rest, morning stiffness lasting less than 30 minutes, joint swelling due to secondary inflammation, and occasionally the formation of bony outgrowths called osteophytes (6). Tenderness may be present at joint lines, and there may be pain upon passive motion. Classic physical exam findings in hand OA include Heberden’s nodes (posterolateral swellings of DIP joints), Bouchard’s nodes (posterolateral swellings of PIP joints), and “squaring” at the base of the thumb (first Carpal-Metarcapal or CMC joints), bony enlargement, crepitus, effusions (non-inflammatory), and a limited range of motion. Patients may also experience bony swelling, joint deformity, and instability (patients complain that the joint is “giving way” or “buckling,” a sign of muscle weakness). (5)4. Lab findings:Rheumatoid Arthritis: Laboratory testing often reveals anemia of chronic disease (increased ferritin, decreased iron and TIBC) and thrombocytosis. Neutropenia may be present if Felty syndrome is present. RF is present in 80-90% of patients with a sensitivity of 69%. In patients who are asymptomatic or those that have arthralgias, a positive RF and especially CCP predicts the onset of clinical RA. Patients with RA with RF, ACPA, or both are designated as having seropositive RA. About 10% of RA patients are seronegative. ESR and levels of CRP are usually elevated in patients with active disease and can be used to assess disease activity. The synovial fluid in RA will also reveal low C3 and C4 levels despite elevated serum levels.(4) Some non-specific inflammatory markers such as ESR, CRP can help you guide your diagnosis of RA.Osteoarthritis:Lab findings are not significant. Clinical diagnosis if the following are present: 1) pain worse with activity and better with rest, 2) age more than 45 years, 3) morning stiffness lasting less than 30 minutes, 4) bony joint enlargement, and 5) limitation in range of motion. Blood tests such as CBC, ESR, rheumatoid factor, ANA are usually normal but usually ordered to rule out an inflammatory process. Synovial fluid should show a white blood cell count less than 2,000/microL, predominantly mononuclear cells (non-inflammatory). X-rays of the affected joint can show findings consistent with OA, such as marginal osteophytes, joint space narrowing, subchondral sclerosis, and cysts; however, radiographic findings do not correlate to the severity of the disease and may not be present early in the disease. (5)5. Treatment Approaches:Rheumatoid Arthritis (RA):There is no cure for RA.The goal of treatment in RA is inducing remission and optimizing quality of life. This is initially done by beginning DMARDs, include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide. Methotrexate is the initial DMARD of choice. Anti-TNF-alpha inhibitors include etanercept, infliximab, adalimumab, golimumab, and certolizumab may be used if DMARDs fail. NSAIDs are used to control joint pain and inflammation. Corticosteroids may be used as a bridge therapy to DMARDs in a newly diagnosed patient with a very active disease. (7) Coronary artery disease has a strong association with RA. RA is an independent risk factor for the development of coronary artery disease (CAD) and accelerates the development of CAD in these patients. Accelerated atherosclerosis is the primary cause of morbidity and mortality. There is increased insulin resistance and diabetes mellitus associated with RA and is thought to be due to chronic inflammation. When treated with specific DMARDs such as hydroxychloroquine, methotrexate, and TNF antagonists, there was a marked improvement in glucose control in these patients. (8) RA is not just a disease of the joints, it is able to affect multiple organ systems.Osteoarthritis (OA):OA treatment aims at reducing pain and improving joint function through a combination of non-pharmacological interventions like exercise programs tailored to strengthen muscles around affected joints, weight management strategies, and assistive devices like braces or walking aids if required (9). Medications including analgesics or nonsteroidal anti-inflammatory drugs may be prescribed for pain relief when necessary. Duloxetine has modest activity in relieving pain associated with OA. Intraarticular glucocorticoid joint injections have a variable response but are an option for those wanting to postpone surgical intervention. In severe cases where conservative measures fail, surgical options like joint replacement may be considered (9). Weight loss is a critical intervention in those who have overweight and obesity; each pound of weight loss can decrease the load across the knee 3 to 6-fold. (5) Summary: Medications (NSAIDs, topical, duloxetine), weight loss, PT, intraarticular injections of corticosteroids, and joint replacement.________________________________Conclusion: Now we conclude episode number 146, “RA vs. OA.” Future Dr. Magurany explained that rheumatoid arthritis is an autoimmune disease that presents with joint pain and inflammation, mostly on hands and small joints, accompanied by morning stiffness longer than 1 hour. The rheumatoid factor and ACPA may be positive in a percentage of patients but not always. The base of treatment is early treatment with disease-modifying antirheumatic drugs to induce remission of the disease. OA affects weight-bearing joints with little to no inflammation, treatment is mainly lifestyle modifications, analgesics, intraarticular injections, and joint replacement.This week we thank Hector Arreaza and Thomas Magurany. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Myasoedova E, Crowson CS & Gabriel SE et al. (2010). Is the incidence of rheumatoid arthritis rising?: Results from Olmsted County, Minnesota, 1955-2007. Arthritis and Rheumatism, 62(6), 1576-1582.Goldring MB & Goldring SR. (2007). Osteoarthritis. Journal of Cellular Physiology, 213(3), 626-634.King LK, March L, Anandacoomarasamy A. Obesity & osteoarthritis. Indian J Med Res. 2013;138(2):185-93. PMID: 24056594; PMCID: PMC3788203.Chauhan K, Jandu JS, Brent LH, et al. Rheumatoid Arthritis. [Updated 2023 May 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Sen R, Hurley JA. Osteoarthritis. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Hunter DJ, Bierma-Zeinstra S. & Eckstein F. (2014). OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for primary hip and knee osteoarthritis: An expert consensus initiative of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) Task Force in collaboration with the Osteoarthritis Research Society International (OARSI). Osteoarthritis Cartilage, 22(7), 363-381.van Everdingen AA, Jacobs JW, Siewertsz Van Reesema DR, Bijlsma JW. Low-dose prednisone therapy for patients with early active rheumatoid arthritis: clinical efficacy, disease-modifying properties, and side effects: a randomized, double-blind, placebo-controlled clinical trial. Ann Intern Med. 2002 Jan 1;136(1):1-12. doi: 10.7326/0003-4819-136-1-200201010-00006. PMID: 11777359.Nicolau J, Lequerré T, Bacquet H, Vittecoq O. Rheumatoid arthritis, insulin resistance, and diabetes. Joint Bone Spine. 2017 Jul;84(4):411-416.Fernandes L, Hagen KB, Bijlsma JWJ et al. (2019). EULAR recommendations for non-pharmacological core management of hip and knee osteoarthritis. Annals of Rheumatic Diseases, 79(6), 715-722.Royalty-free music used for this episode: "Driving the Point." Downloaded on July 29, 2023, from https://www.videvo.net/ 

Episode 145: Family Planning for the LGBTQIA+Future Dr. Hoque explains how to assist with family planning for the LGBTQIA+ community. Some principles such as avoiding unintended pregnancies and reducing and early treatment of STIs are discussed.  Written by Ashfi Hoque, MBA, MS4, Ross University School of Medicine. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Arreaza: Welcome to episode 145 of the Rio Bravo qWeek podcast. My name is Hector Arreaza, a faculty member of the Rio Bravo Family Medicine Residency Program.Ashfi: Hello everyone, I am Ashfi Hoque a 4th-year medical student at Ross University School of Medicine. I am from Long Beach, California. Patient advocacy and patient-centered care have always been a priority of mine. I’ve volunteered for years at the LGBT+ center in Weho and Long Beach. Today we will be discussing Family Planning for everyone while learning ways to become LGBTQIA+ inclusive. Arreaza: Yes, family planning is important, and I’m glad you included all types of families. I believe medical care must be offered to everyone, and I also believe in freedom of conscience, that’s why I can freely express that I support traditional family for me. Why did you choose this topic?Ashfi: I chose this topic because my partner recently went to get her physical. Her provider had an extensive conversation about family planning and even discussed the anticipated cost of freezing her oocytes. I really loved the way this provider went about the conversation so I started researching ways I can support my community and also teach others to provide Queer inclusive medical care. What is LGBTQIA+?LGBTQIA+ stands for Lesbian, Gay, Bisexual, Trans, Queer, Intersex, Asexual, etc. The community will be referenced as the Queer community, an umbrella term for people who are not heterosexual or not cisgender. There are many inequalities that the community faces and we can do our due diligence to educate ourselves continuously and be aware that terminology and health needs may change. We have another Rio Bravo episode, Caring for LGBTQ+ Patients on Episode 103, that discusses healthcare disparities, but during this episode, we will be diving into an introduction to bridging health gaps, creating health equity, and building trust with the community. A 2023 Global Survey found that the self-identified Queer community represents 9% of the population, while the true estimate may be higher due to safety concerns. While diabetics are 10-13% of the population. These statistics show that as a medical provider, you'll encounter Queer patients more often than you think. One of the healthcare issues that Queer folks face is a lack of family planning.What is Family Planning?The World Health Organization (WHO) defines family planning as “the ability of individuals and couples to anticipate and attain their desired number of children and the spacing and timing of their births. It is achieved through the use of contraceptive methods and the treatment of involuntary infertility.”Family planning serves three critical needs: Avoiding unintended pregnanciesReducing sexually transmitted diseases (STDs)Early treatment of STDs to reduce rates of infertilityWhen discussing family planning for patients, here are some examples of questions you can ask. What name may I use to address you?What are your pronouns?What is your gender? (Only if necessary for care, what is your assigned sex at birth?)Are you sexually active?What is the gender(s) of your partner(s)?Are you concerned about unintended pregnancy?Are you currently using any contraceptive measures?Are you taking any precautions to reduce STI/STD such as physical barriers like condoms, dental dams, or any harm reduction such as PrEP?What kind of STI/STD screening are you requesting?Do you need me to request additional labs such as oral or anal swabs?Those questions must be asked in a natural, non-judgmental way. While STD/STI screening and treatment is part of family planning, the part that we tend to neglect is the desire for Queer folks to build a family. Why is Family Planning Important for the LGBTQIA+ community?The Queer community gained the legal right to marry eight years ago, in 2015. They did not have the nationwide right to adopt until the last state, Mississippi, overturned the unconstitutional restrictions for the Queer community to adopt in 2016. A UCLA study in 2018 titled, “How many same-sex couples in the US are raising children?” reported cis-heterosexual couples: 3% are raising at least one adopted child and 95% are raising biological children while same-sex couples: 21.4% are raising at least one adopted child and 68% have a biological child. When it comes to family planning, there is more than adoption for Queer people. Queer folks are not offered the same pregnancy planning options, such as cis hetero-couples who are experiencing infertility or cis-women planning for advanced maternal age pregnancy. However, the options are quite similar. These options require specific types of planning, and that information can be provided to patients by their primary care doctor. A couple needs to know their options and consider the long-term financial planning necessary for surrogacy, in vitro fertilization (IVF), or donor insemination. The main difference for many Queer couples is the method of conception needed. Depending on sexual orientation and gender identity, patients may have varying reproductive needs as part of their family planning. We cannot make assumptions about how family planning should look and need to remember this journey looks different from person to person and couple to couple.How to approach family planning with the LGBTQIA+ community? Basic tenants of providing medical care for queer patients: Clinics specializing in Queer family planning found patient-centered care leads to better outcomes. The best approach is to be mindful, conscious, and to communicate without assumptions. We have to start with providers building trust, being honest, showing sensitivity assisting with reproductive services, and working towards being more knowledgeable about Queer parenthood. A provider could ask questions such as: Would you like information about family planning?What do you imagine your future family to look like?Would you like to see options and potential costs?Would you need a referral for a specialist?Or it can be as simple as being honest about your scope of knowledge by stating, “I am not well versed in LGBTQIA+ community issues but what ways can I support you?” It is ethically appropriate to transition care to a physician with better knowledge if you feel unable to assist a person from the LGBTQ+ community. Make sure to do it in a polite and respectful way.Gender inclusive: With more people openly identifying as non-binary and trans, there is a need for a gender-neutral approach to discussing a patient’s biological and reproductive needs. First, we will avoid assuming gender identity based on the biological sex of a patient. Episode 14 of Rio Bravo does a great job of breaking down gender diversity and the difference between gender identity and biological sex. For transgender and nonbinary patients, providing care for medical transitioning often includes conversations about family planning before starting HRT. It is common to ask patients about to begin HRT if they would like to freeze their sperm or eggs. Second, we want to avoid assuming anything based on what reproductive organs a patient has. We can ask a patient about their intention to start a family. Avoid asking if a trans patient has received transitional surgery (bottom surgery) unless it is completely necessary for the care we are providing. Instead, it is appropriate to ask the patient if birthing is an option? Have you given birth before? Were there any complications? Is there any current hormonal treatment? This mindful strategy is also useful for patients who may have limitations in: producing oocytes or sperm, the ability to house a fetus in utero, or implantation and fertility. Third, we are going to address our underlying beliefs and assumptions about gendered parenthood. Parenthood is almost always thought of as motherhood and fatherhood, but this can be alienating for transgender patients. There are many possible ways of being a parent, and to be inclusive let’s consider the possibility of a masculine woman or transmasculine man being a birthing parent or of a transgender woman being the mother of a child without giving birth to the child. There are many more scenarios we can discuss at another point. In the interest of time, we are going to shift into discussing family planning for lesbian and gay people and couples. Sexuality inclusive:For homosexual cis-gendered people who are single or in relationships, family planning can look similar to couples facing infertility issues. When having family planning conversations with these patients, a provider should ask broad, unassuming questions. If you have established that a queer person or couple wants a child, then you can ask if they have a family plan. If the patient or couple has a plan, follow the couple’s lead. If the patient(s) do not have a plan, then you can begin to ask questions like: Do you have someone in mind to be a birth giver? Do you have a sperm donor? Do you have an egg donor? These questions are a great transition into discussing the following options for family planning.What are the options for having a newborn and the financial and ethical cost?Having a child can cost up to $100k, and this does not even include the cost of childcare. Infertility treatment is not covered by regular insurance, so patients need either infertility insurance or private financing to cover the cost of treatment. However, fertility insurance does not cover same-sex couples. There is a large emotional, physical, and ethical cost to deciding which route to choose. Let’s discuss options and obstacles.1. Donor Insemination: The most affordable route is having a birth-giving parent who is fertile with a known sperm donor. This method can be as simple as using a syringe to inseminate the uterus-carrying person, but we need to consider necessary attorney fees to terminate the parental rights of the sperm donor. Sperm from a sperm bank requires an extensive workup including STD panel, HIV, and genetic disorder screening. The sperm donor gives up all parental rights during the process. The price of these procedures is constantly changing and depends on location.California Cryobank costs start at $1200 for anonymous donors and $1900 for identification disclosure donor which the child will receive information about the donor at age 18. Selecting a donor can include specifics such as race, talents, education, hobbies, physical attributes, and showing donor baby photos. There are two common insemination processes:Intracervical insemination: semen inside the cervical opening and covers the cervixIntrauterine insemination: semen is inserted through the cervix and placed directly into the cavityThe next option jumps up in cost significantly.2. Freezing Eggs (Oocyte Cryopreservation):Pacific Fertility Center Los Angeles, reports a single cycle of egg freezing can cost $6-10k per freezing cycle and may need multiple cycles without medication. The medications are typically around $3-6k depending on how much your body needs. Storage is an additional cost of $700-$1,000 a year. This is an option for parents planning pregnancy during advanced ages.3. In Vitro Fertilization (IVF): It is a process where an oocyte is collected similarly to freezing eggs but fertilized with a partner’s or donor’s sperm.Pacific Fertility Center Los Angeles reports it costs $8-13k per cycle of fertilization. It is an option for those who have issues with infertility, previous pelvic inflammatory diseases, surgeries, and issues with implantations.4. Surrogacy: This is the process of hiring a professional birthing surrogate to carry an embryo. This is an alternative option for couples who decline or cannot carry a pregnancy. The surrogate has no legal rights or biological relation to the fetus. Family Tree Surrogacy reports it costs about $45-65k.5. Adoption: Foster care adoption in California can be $1-5k. American Cost of Adoption, reports the cost of adoption for infants in California $40-70k including the medical expenses for the birth-giving person and legal expenses for the process. Versus adopting an infant from another country due lack of resources and poverty may better their lives or cause a higher demand for infants which may be an ethical issue. Also, transcultural adoption where the race of the parents and the children are different, and navigating culture and race with the children. Adoptees have reported having racial identity crises.With all these studies, it is well documented that providers will not be perfect at giving care to the Queer community. These studies do not represent every queer person and do not take the intersectionality of race, class, or gender identity into consideration. It is our job as providers to be supportive of all types of patients in order to increase their access to proper medical care. _______________Conclusion: Now we conclude episode number 145, “Family Planning for the LGBTQIA+.” Future Dr. Hoque explained how queer people can be included in family planning conversations, even before heterosexual couples. She described some options such as donor insemination, freezing eggs, IVF, and adoption. Dr. Arreaza explained that it is important to ask reproductive questions in a natural, non-judgmental way to all your patients, and refer to another professional when needed. This week we thank Hector Arreaza and Ashfi Hoque. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American Adoptions—How Much Does a Private Adoption Cost in California? [And Why?]. (n.d.). Retrieved July 14, 2023, fromhttps://www.americanadoptionsofcalifornia.com/adopt/cost-of-adoption-in-californiaAmerican Adoptions—LGBTQ Adoption: Can Same-Sex Couples Adopt? (n.d.). Retrieved July 14, 2023, fromhttps://www.americanadoptions.com/adopt/LGBT_adoptionCarpenter, E. (2021). “The Health System Just Wasn’t Built for Us”: Queer Cisgender Women and Gender Expansive Individuals’ Strategies for Navigating Reproductive Health Care. Women’s Health Issues, 31(5), 478–484.https://doi.org/10.1016/j.whi.2021.06.004Choosing the Right Sperm Donor | California Cryobank. (n.d.-a). Retrieved July 14, 2023, from HTTPS://www.cryobank.com/how-it-works/choosing-your-donor/Choosing the Right Sperm Donor | California Cryobank. (n.d.-b). Retrieved July 14, 2023, from HTTPS://www.cryobank.com/how-it-works/choosing-your-donor/Cost of Egg & Embryo Freezing in the U.S. | PFCLA. (n.d.). Retrieved July 14, 2023, fromhttps://www.pfcla.com/blog/egg-freezing-costs. (2012, April 25).Donor Insemination. American Pregnancy Association.https://americanpregnancy.org/getting-pregnant/donor-insemination/Hollingsworth, L. D. (2003). International adoption among families in the United States: Considerations of social justice. Social Work, 48(2), 209–217.https://doi.org/10.1093/sw/48.2.209In vitro fertilization (IVF): MedlinePlus Medical Encyclopedia. (n.d.). Retrieved July 14, 2023, fromhttps://medlineplus.gov/ency/article/007279.htmIngraham, N., Fox, L., Gonzalez, A. L., & Riegelsberger, A. (2022a). “I just felt supported”: Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics. PLOS ONE, 17(7), e0271691.https://doi.org/10.1371/journal.pone.0271691Ingraham, N., Fox, L., Gonzalez, A. L., & Riegelsberger, A. (2022b). “I just felt supported”: Transgender and non-binary patient perspectives on receiving transition-related healthcare in family planning clinics. PLOS ONE, 17(7), e0271691.https://doi.org/10.1371/journal.pone.0271691Ingraham, N., & Rodriguez, I. (2022a). Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics. Transgender Health, 7(1), 36–42.https://doi.org/10.1089/trgh.2020.0110Ingraham, N., & Rodriguez, I. (2022b). Clinic Staff Perspectives on Barriers and Facilitators to Integrating Transgender Healthcare into Family Planning Clinics. Transgender Health, 7(1), 36–42.https://doi.org/10.1089/trgh.2020.0110Klein, D. A., Malcolm, N. M., Berry-Bibee, E. N., Paradise, S. L., Coulter, J. S., Keglovitz Baker, K., Schvey, N. A., Rollison, J. M., & Frederiksen, B. N. (2018). Quality Primary Care and Family Planning Services for LGBT Clients: A Comprehensive Review of Clinical Guidelines. LGBT Health, 5(3), 153–170.https://doi.org/10.1089/lgbt.2017.0213PFCLA. (n.d.). The Cost of IVF in California. Retrieved July 14, 2023, fromhttps://www.pfcla.com/blog/ivf-costs-californiaPODCAST. (n.d.). Rio Bravo Residency. Retrieved July 14, 2023, fromhttps://www.riobravofmrp.org/qweek/episode/fcb76527/episode-103-caring-for-lgbtq-patientsRotabi, K. S. (n.d.). From Guatemala to Ethiopia: Shifts in Intercountry Adoption Leaves Ethiopia Vulnerable for Child Sales and Other Unethical Practices.Smoley, B. A., & Robinson, C. M. (2012). Natural Family Planning. American Family Physician, 86(10), 924–928.Surrogate Compensation | How Much Do Surrogater Paid in CA? (n.d.). Https://Familytreesurrogacy.Com/. Retrieved July 14, 2023, fromhttps://familytreesurrogacy.com/blog/surrogate-pay-california/The National Academies Press. (n.d.). Retrieved July 14, 2023, fromhttps://nap.nationalacademies.org/thisisloyal.com, L. |. (n.d.). How Many Same-Sex Couples in the US are Raising Children? Williams Institute. Retrieved July 14, 2023, fromhttps://williamsinstitute.law.ucla.edu/publications/same-sex-parents-us/Royalty-free music used for this episode: "Rain in Spain." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Episode 144: Risk Factors for Pediatric Overweight and ObesityFuture Dr. Lal describes multiple risk factors associated with childhood overweight and obesity. Dr. Arreaza adds comments about caring for pediatric patients with obesity. Practice guidelines are mentioned throughout this episode.Written by Krustina Lal, MSIII, Western University College of Osteopathic of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction:Obesity is one of the most common pediatric chronic diseases affecting 14.4 million children and adolescents (about twice the population of New Jersey).A recent simulation study from the US found that by 2030, a staggering 55–60% of today’s children will be obese.1 in 4 children in California have obesity.Research shows that the ages between 0 and 5 years is a critical period in the development of overweight and obesity. Obesity has complex genetic, physiologic, socioeconomic, and environmental contributors. Pediatricians and other primary care physicians need to be aware of the risk factors for pediatric obesity to provide early anticipatory guidance for prevention, close monitoring, and early intervention when the weight trajectory increases.We will discuss the risk factors for children and adolescents to develop overweight and obesity, we will be diving deep into general, environmental, and familial factors. This is based off the AAP (American Academy of Pediatrics) “Clinical Practice Guidelines for the Evaluation and Treatment of Children and Adolescents with Obesity.” This guideline was published in February 2023, it is available online for free, and this is the first edition.A. General Factors- Socioeconomic StatusA longitudinal analysis of predominantly non-Hispanic white children in the United States found that low socioeconomic status before 2 years of age was associated with higher obesity risk by adolescence in both boys and girls.Poverty is associated with toxic stress, limited access to healthy foods, and low physical activity.-Children in Families That Have Immigrated to the USRecently arrived immigrants tend to be healthier than their US-born counterparts. However, as immigrants try to adjust to a new culture, they may adopt Americanized foodways, which are high in fat, sugar, and salt.Second-generation Hispanic immigrants are 55% more likely to have obesity than nonimmigrant white children, whereas first-generation Asian immigrants had a 63% lower risk of having obesity.Larger body sizes may be an indication of health and wealth in some cultures. This cultural factor may make it more difficult for parents to understand the gravity of their children’s obesity.Comment: This is a common concern among Hispanic families that bring their children to the clinic to get “vitamins” to gain weight because they look “sick,” but their BMIs are normal. PCPs should be prepared to address that concern in the clinic.B. Neighborhood and Community Environments-School EnvironmentThe presence of fast foods, vending machines, and/or sweetened beverages in schools may negatively influence children’s food choices, this effect is larger in younger grades.One day I went to have lunch with Devin, I liked that they had to go through the salad bar before they went to get other foods. They had the choice between vegetables or fruits.-Lack of Fresh Food AccessNeighborhood food environment has been shown to have a mixed association with children’s BMI.Children and families in these settings may be unable to access fresh fruits and vegetables and safe physical activity spaces. There may be limitations in transportation, cost, affordability, and availability.-Fast food proximityLow-priced, calorie-rich fast foods with elevated levels of saturated fat, simple carbs, sugar, and sodium are commonly sold in fast food restaurants. Because they are easily available, they taste good, and they are strategically marketed, fast foods tend to be popular among children and adolescents.Some studies, not all, have shown an association between fast food locations near schools and obesity in children; a stronger association is seen in populations with lower socioeconomic status.-Access to safe physical activityGreater exposure to green space has been shown to be associated with higher levels of physical activity and a lower risk of obesity.That is something we have to recommend during our well-child visits. We are seeing a lot of aversion to going outside among the new generations. Going out seems to be torture when they find so much fun inside their houses (countless amounts of videos, video games, air conditioning/heater, etc...). A strategy for parents can be recommended 1 hour of playing outside before allowing screen time.-Environmental Health  Exposure to environmental hazards during the prenatal period, infancy, and childhood can have impacts on the health and well-being of children.Exposure to endocrine-disrupting chemicals may occur through breastfeeding, inhalation, ingestion, or absorption through the skin. We are basically surrounded by hazardous chemicals used in cleaning agents, food packaging, pesticides, fabrics, upholstery, etc. Exposure during early childhood can affect the programming of several systems, including endocrine and metabolic systems, which may affect BMI, cardiovascular, and metabolic outcomes later in life. C. Family and home environment factors-Parenting feeding styleFour types of parent feeding styles have been described:AuthoritativeAuthoritarianPermissive or indulgentNegligentAuthoritative feeding is considered protective against excessive weight gain. Children tend to eat more healthy foods, be more physically active, and have healthier BMI compared with children raised in homes with authoritarian, permissive or indulgent, or negligent parenting styles.-Sugar-sweetened beverages within the homeA systematic review of 20 prospective cohort studies and randomized controlled trials from 2013 to 2015 found that sugar-sweetened beverages (SSBs) were positively associated with obesity in children in all but 1 study.Comment: Sugary drinks are an easy way to get calories in your body. People tend to think that drinks don’t count, but they can be loaded with carbs. Orange juice can have up to 25 grams of sugar in a cup, some sodas may have double, and both are high in sugar.-Portion sizes and snacking behavior Positive association but need long-term studies-Dining out and family mealsEating outside of the home—irrespective of the type of restaurant establishment visited—is associated with a higher risk of weight or BMI gain.Conversely, 2 meta-analyses found that an increased frequency of eating family meals was associated with a lower risk of childhood obesity.-Screen time – This is one of the major struggles we have as parents. It’s a daily fight.A recent meta-analysis reported a 42% greater risk of being overweight or obese with more than 2 hours per day of television (TV) compared with 2 or fewer hours.Meta-analysis showed that even short exposure to unhealthy food and beverage marketing targeted at children resulted in increased dietary intake and behavior during and after the exposure.Marketing occurs via television, websites, online games, supermarkets, and outside schools.Male children and adolescents tend to spend more time on media screen devices and other Internet technology than female children and adolescents do.There is no conclusive guideline about it, but in general, we can recommend sleep hygiene to avoid insomnia or abnormal sleep patterns, such as avoiding “screens” 1 hour before bed.-Sedentary behaviorNo association. However, many confounding factors include physical activity, screen time, and unhealthy food intake.-Sleep durationChildren 13 years and younger with short sleep duration (∼10 hours) had a 76% increased risk of being overweight or obese compared with their counterparts with longer sleep duration (12.2 hours).Sleep restriction may be associated with increased calorie consumption, fatigue, and decreased physical activity.-Environmental smoke exposureChildren under 8 years old exposed to environmental tobacco smoke (ETS) have been found to have higher BMI compared with their nonexposed counterparts.I wonder If this is a direct or indirect effect of smoke.-Psychosocial stressA meta-analysis showed that prenatal psychological stress was associated with a higher risk of childhood and adolescent obesity.Psychosocial and emotional issues may lead to weight gain through maladaptive coping mechanisms, including eating in the absence of hunger to suppress negative emotions, appetite up-regulation, low-grade inflammation, decrease in physical activity, increase in sedentary behavior, and sleep disturbance. Depression has been shown to be a risk factor in both pediatric and adult obesity.-Adverse childhood experiencesACEs include a history of physical, emotional, or sexual abuse; exposure to domestic violence; household dysfunction from parental divorce or substance abuse; economic insecurity; mental illness; and/or loss of a parent because of death or incarceration.A study found that having many ACEs increased two times the risk of children having overweight or obese compared with children with no history of ACEs. Stress may result in abnormal coping strategies—such as binge eating, eating in the absence of hunger, impulsive eating, and poor sleep hygiene—which may result in further weight gain.Summary: The consequences of childhood obesity are far-reaching and extend beyond physical health issues. Children with obesity are more likely to experience a range of health complications, including type 2 diabetes, high blood pressure, sleep apnea, joint problems, and psychological issues such as low self-esteem and depression. Moreover, children with obesity are at a higher risk of carrying their weight-related problems into adulthood, increasing their susceptibility to chronic conditions such as cardiovascular disease, certain types of cancer, and premature mortality. As medical providers, we all need to keep general, environmental, and familial factors in mind when discussing weight changes among our pediatric patients. Having knowledge of such influences will help us intervene and prevent further progression. ______________________________Conclusion: Now we conclude episode number 144, “Risk Factors for Pediatric Overweight and Obesity.” Future Dr. LaL reminded us that childhood obesity is a disease linked to multiple risk factors, including but not limited to: low socioeconomic status, lack of access to safe spaces for exercise, parenting feeding styles, sleep disturbances, and adverse childhood events. Dr. Arreaza emphasized the importance of providing obesity care with kindness and empathy, especially when caring for pediatric patients.This week we thank Hector Arreaza and Krustina Lal. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics February 2023; 151 (2): e2022060640. 10.1542/peds.2022-060640. https://publications.aap.org/pediatrics/article/151/2/e2022060640/190443/Clinical-Practice-Guideline-for-the-Evaluation-and?autologincheck=redirected.Weihrauch-Blüher, S., Wiegand, S. Risk Factors and Implications of Childhood Obesity. Curr Obes Rep 7, 254–259 (2018).Hemmingsson, E. Early Childhood Obesity Risk Factors: Socioeconomic Adversity, Family Dysfunction, Offspring Distress, and Junk Food Self-Medication. Curr Obes Rep 7, 204–209 (2018).Royalty-free music used for this episode: "Latina Havana Boulevard." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Episode 143: Pulmonary Cocci BasicsDr. Lovedip Kooner explains the history, diagnosis, and treatment of pulmonary coccidioidomycosis (cocci for short.) Disseminated cocci infection was also discussed. Dr. Arreaza added some anecdotes of patients seen with this infection.  Written by Lovedip Kooner, MD. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition:Coccidioidomycosis, also known as Valley Fever, is an infection caused by the fungi Coccidioides immitis and Coccidioides posadasii. Coccidioides is also referred to as cocci. Generally speaking, C. immitis is found in California and C. posadasii is found in Arizona, and Central and South America. More recently Cocci has also been found as far north as Washington and British Columbia. History:The fungal infection was first reported by Wernicke and Posadas in Argentina in 1892 where they described a case where a man had cutaneous cocci of the head, arm, and trunk. To this day, the head is preserved in Argentina. 4 For many years, only disseminated cases were recognized and described as “coccidioidal granulomas.” The work of Dixon and Gifford in 1935 elucidated that a pneumonic disease of unknown cause termed “San Joaquin Valley Fever” was, in fact, the primary coccidioidal infection and the port of entry of almost all coccidioidal disease. Initial infection occurs predominantly by inhalation of aerosolized arthroconidia and rarely by direct cutaneous inoculation.1,2Coccidioides spp. survive best in areas with low rainfall (12–50 cm per year), limited winter freezes, and alkaline soils. With climate change models, predicting the geographical range expansion.These dimorphic fungi exist in a mycelial form in the soil. Coccidioides species have been found in animal burrows near the Kern River and in Armadillo burrows in South American countries like Brazil. The mycelia produce arthroconidia (spores) that are ultimately airborne and inhaled.The inoculum required for infection is low and in animal models as few as a single arthroconidium may cause infection.3 Infection:Once arthroconidia are inhaled into the lung, there is typically a 1-3-week incubation period. The arthroconidia undergo morphologic changes into spherules, which are large structures that contain endospores.4 As spherules mature, they rupture and release endospores. Endospores can be spread hematogenous or through lymphatics to essentially any organ, leading to the development of new spherules and potentially disseminated disease.5 Not everyone who inhales the arthroconidia gets the infection. Clinical Manifestations.About 60% of patients who inhale arthroconidia are asymptomatic. 30% have a mild respiratory illness, like the flu. 10% have a more serious disease course and are diagnosed. Other symptoms may include fever, drenching night sweats, and weight loss. Extreme fatigue that limits baseline activity may also raise concerns. Symptom onset up to 2 months after endemic exposure should lead to coccidioidomycosis on the differential. Coccidioidomycosis cases have been documented in Michigan, Europe, and China. These cases were of people who traveled to endemic areas for as little as a few days and then were later diagnosed. 1-3% of all coccidioidomycosis cases are disseminated, severe, or chronic pulmonary infections. If undiagnosed, coccidioidomycosis may lead to significant morbidity and mortality. Dissemination sites include the skin, lymph nodes, bones, and Central Nervous System (CNS) which is the most severe. Any organ can be infected, including documented cases of the prostate and adrenal gland. Arreaza: Recap: 60% are subclinical, 30% are mild, 10% serious, 1-3% are disseminated. What are some risk factors for severe infection? Should I stop biking?Risk factors for severe infection:Severe pulmonary infections can happen in anyone but occur more commonly in diabetics, tobacco users, and people older than 65 years of age.Oceanic or Filipino ethnicity and black or African American have a higher rate of dissemination. Immunosuppression, including HIV, transplant patients, and immunosuppressive medications like corticosteroids or TNF-alpha inhibitors have been shown to be risk factors for dissemination. Pregnant patients, particularly in the third trimester have higher rates of severe infection as well.Arreaza: How do we diagnose the disease?Diagnosis:Diagnosis is commonly made serologically. EIA (enzyme immunoassay) is used more often. There are more false positives than false negatives and varies by manufacturer. Kern County Health Department uses Immunodiffusion IgG and IgM and Complement Fixation are used. Immunodiffusion IgG and IgM are scaled by non-reactive, weakly reactive, reactive and strongly reactive. Compliment fixations are scaled by a ratio/dilution. Serum Compliment fixations Culture or histopathology with endo-sporulating spherules can also be used to diagnose. Serological diagnoses are less reliable early in the disease process and may take up to 6 weeks to be positive. Arreaza: Let’s talk about the most common manifestation of cocci, pulmonary.Primary pulmonary infections:In endemic regions, 25 % of community-acquired pneumonia may be attributed to coccidioidomycosis. The primary pulmonary infection may be associated with erythema nodosum or erythema multiforme. Imaging typically demonstrates segmental or lobar consolidation and mediastinal adenopathy. 5-15% of cases are complicated by effusion. Optimal treatment is unclear, due to lack of prospective, randomized controlled clinical trials. Retrospective studies have shown that about 95% of immunocompetent cases resolve on their own without treatment. Arreaza: How do we treat it? Treatment:The most recent guidelines are the 2016 Infectious Diseases Society of America Clinical Practice Guideline for the Treatment of Coccidioidomycosis (IDSA), and they recommend patient education, close observation, and supportive measures such as reconditioning physical therapy for mild or non-debilitating symptoms, or who have substantially improved or resolved their clinical illness by the time of diagnosis.The Valley Fever Institute treats most patients with primary disease and all patients with disseminated disease; including coccidioidal meningitis, which requires lifelong treatment with a triazole.A double-blind randomized clinical trial done by the mycosis study group showed no superiority of treatment between either fluconazole or itraconazole.Fluconazole remains the mainstay of treatment. Fluconazole suppresses the growth of fungi, it does not directly kill fungi.Fluconazole dosage varies from person to person, and institution to institution. Institutions from Arizona are more likely to treat with 400mg while Valley Fever Institute tends to give a minimum of 600mg-800mg/daily. Duration of treatment is variable; taking into consideration symptoms and serology. Side effects of fluconazole include xerosis, alopecia, and fatigue.Therapeutic drug monitoring is a debated topic amongst experts. The Valley Fever Institute routinely monitors drug levels.Arreaza: Fluconazole is the mainstay of treatment. For our primary care peers, you can start fluconazole, making sure there is no contraindication or medication interactions.Failure of treatment.Treatment can be stopped for intolerance and/or for treatment failure. In either case, switching to other triazoles is recommended. Those triazoles include: itraconazole, posaconazole, or voriconazole. Amphotericin B is also used for refractory cases. Each has its own dosages and adverse effect profile. Disseminated disease requires closer monitoring and possibly IV amphotericin, or intrathecal amphotericin. Arreaza: What can we expect about the future of treatment?Future of coccidioidomycosis treatmentAlthough there are not any FDA-approved vaccines for fungal infections, there are vaccines being developed that have shown promise in animal models for coccidioidomycosis. Different drugs are also under development that have different targets than triazoles like fluconazole. The role of therapeutic drug monitoring may become clearer.Further research is also needed to provide more specific guidelines.We are optimistic about the future. We see this disease commonly in the clinic and the hospital, and many patients may become disabled in cases of complicated/disseminated cocci. This is just an introduction for our listeners to keep learning about this disease.A message for primary care doctors: In a patient with respiratory illness, and you suspect pulmonary cocci, order serology, and chest x-ray, and if you find pulmonary cocci, start treatment with fluconazole. Learn to identify patients at risk for dissemination/severe disease and refer to infectious disease when needed. ______________________Conclusion: Now we conclude episode number 143, “Pulmonary cocci basics.” Dr. Kooner explained that this fungal infection can present with symptoms of community-acquired pneumonia. He explained that infection can disseminate to other organs or cause severe disease in a small percentage of infected patients. Because of the consequences of severe infection, Dr. Arreaza recommended primary care providers keep a high level of suspicion when patients present with any symptoms compatible with cocci infection in endemic areas.This week we thank Hector Arreaza and Lovedip [pronounced as Love-DEEP] Kooner. We give special thanks to the Valley Fever Institute for providing information for this episode. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Johnson, Royce H et al. “Coccidioidomycosis: a review.” Journal of investigative medicine: the official publication of the American Federation for Clinical Research vol. 69,2 (2021): 316-323. doi:10.1136/jim-2020-001655.Wernicke R: Ueber einen protozoenbefund bei mycosis fungoides. Zentralblatt Bakteriol 1892; 12:859-861.Posadas A. Un nuevo caso de micosis fungiodea con posrospemias. An Cir Med Argent 1892; 15:585-97.Bays, Derek J, and George R Thompson 3rd. “Coccidioidomycosis.” Infectious disease clinics of North America vol. 35,2 (2021): 453-469. doi:10.1016/j.idc.2021.03.010.Nnadi NE, Carter DA. Climate change and the emergence of fungal pathogens. PLoS Pathog. 2021 Apr 29;17(4):e1009503. doi: 10.1371/journal.ppat.1009503. PMID: 33914854; PMCID: PMC8084208.Gorris ME, Treseder KK, Zender CS, Randerson JT. Expansion of Coccidioidomycosis Endemic Regions in the United States in Response to Climate Change. Geohealth. 2019 Oct 10;3(10):308-327. doi: 10.1029/2019GH000209. PMID: 32159021; PMCID: PMC7007157.Cordeiro, R A et al. “Phenotypic characterization and ecological features of Coccidioides spp. from Northeast Brazil.” Medical mycology vol. 44,7 (2006): 631-9. doi:10.1080/13693780600876546.Davis, Matthew R et al. “Tolerability of long-term fluconazole therapy.” The Journal of antimicrobial chemotherapy vol. 74,3 (2019): 768-771. doi:10.1093/jac/dky501.Galgiani, J N et al. “Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group.” Annals of internal medicine vol. 133,9 (2000): 676-86. doi:10.7326/0003-4819-133-9-200011070-00009.Ampel, Neil M. “THE TREATMENT OF COCCIDIOIDOMYCOSIS.” Revista do Instituto de Medicina Tropical de Sao Paulo vol. 57 Suppl 19, Suppl 19 (2015): 51-6. doi:10.1590/S0036-46652015000700010.Royalty-free music used for this episode: "Rain in Spain." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Episode 142: Tirzepatide IIFuture Dr. Beuca explains that tirzepatide has shown benefits in patients with obesity that go beyond its weight-reducing effects and includes reduction of blood pressure, among others. Dr. Arreaza explains that Wegovy (semaglutide approved for weight loss) is also very beneficial for weight loss and explains.  Written by Maria Beuca, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Maria: Hello everyone, today is June 2, 2023, and we want to re-visit our discussion about the drug Tirzepatide from our May 19th, 2022. A little re-cap for those of you who don’t know, tirzepatide, also known by the brand name Mounjaro, is a drug that was approved by the FDA a year ago for the treatment of type 2 Diabetes. It is similar to the drug Semaglutide, also known by the brand name Ozempic which many of you may be more familiar with, thanks to the Kardashians and other celebrities making it popular as a “weight loss” drug. Arreaza: The brand name for weight semaglutide is Wegovy.Maria: Both of these drugs are injected once a week and mimic the effect of the incretin hormone GLP-1 by binding to its receptor. Incretin hormones are a group of hormones that cause insulin to be released from the pancreas after eating to help lower blood sugar levels.  These incretin hormones also help suppress the appetite, causing you to eat less and lose weight. Tirzepatide is different because it is the first drug to mimic the action of two hormones, both GLP-1 and GIP. In our last episode, we also discussed the SURPASS-2 study that showed tirzepatide to be superior to semaglutide because of this dual incretin action, with greater weight loss, lower HA1c levels, and lower triglyceride and VLDL levels. At that time, we also mentioned the SURMOUNT-1 Phase 3 clinical trial that was ongoing at the time. Well, it is now complete, and the results are in. There were 2,539 obese or overweight participants without diabetes in the study who lost between 16-22.5% of their starting weight on Tirzepatide. On 15 mg dose, participants lost about 52 lbs (24 kg), on 10 mg 49 lbs (22 kg) and on 5 mg about 35 lbs (16 kg), but those on the placebo lost only 2.4% or about 5 lbs (2 kg). As you can see there is very little difference in weight loss between the 10 mg dose and the 15 mg dose, although a big difference is seen compared to the 5 mg dose. It’s important to note that they took Tirzepatide for 72 weeks or a year and a half. Arreaza: That’s very significant weight loss. It is important to emphasize that these patients did NOT have diabetes. Maria: These weight loss results have proven to be comparable to bariatric surgery. The study also showed improvement in cardiovascular and metabolic risk factors such as lower blood pressure, fasting insulin, lipid levels and even aspartate aminotransferase levels in comparison to the placebo. By the end of the study, more than 95% of the participants who had pre-diabetes had converted to normal glucose levels. This study was so impressive that it was presented at the 82nd Scientific Sessions of the American Diabetes Association and was also published in The New England Journal of Medicine. Arreaza: It seems like tirzepatide is ahead of the game for weight loss.Maria: Although it is approved as a drug for diabetes, the next step is to approve it for weight loss and to begin treating obesity as a chronic disease that needs to be treated. Maria: And this makes sense. Currently, more than 4 in 10 American adults have obesity, and obesity is the cause of many other conditions. Just yesterday, I was seeing patients in the orthopedic clinic and I had several patients being seen for knee pain due to obesity, and they are postponing surgery because they have been losing weight on tirzepatide and are already feeling better. I think avoiding knee surgery alone is a pretty good reason to approve these drugs for weight loss, but there are many other conditions that are improved by weight loss. Arreaza: My anecdotes are related to semaglutide, but I can imagine that this may also apply to tirzepatide. I had a patient who was able to stop all antihypertensive medications because of 40-lb weight loss. Maria: Dr. Caroline Apovian, director of the Center for Weight Management and Wellness at Brigham Women’s Hospital, states that “If everybody who had obesity in this country lost 20% of their body weight, we would be taking patients off all these medications for reflux, for diabetes, for hypertension. We would not be sending patients for stent replacement.”Maria: Last month, officials from Eli Lilly, the company that makes tirzepatide, stated that they are hoping to have a fast-track approval to sell it for chronic weight management by sometime this year. The problem is that many of these patients who were prescribed Tirzepatide have not been able to get it because it has been out of stock for the last few months in all the local pharmacies. They get the prescription, start taking Tirzepatide and begin to lose weight or improve their blood sugar levels and then it is out of stock and now you have people with Diabetes who have gotten off insulin because Tirzepatide worked so well and suddenly they can’t get it and are at risk for getting pretty sick without it. Arreaza: The manufacturer of Wegovy announced this, “we will only be able to supply limited quantities of 0.25 mg, 0.5 mg, and 1 mg dose strengths to wholesalers for distribution to retail pharmacies which will not meet anticipated patient demand. We anticipate that many patients will have difficulty filling Wegovy® prescriptions at these doses through September 2023. We do not currently anticipate supply interruptions of the 1.7 mg and 2.4 mg dose strengths of Wegovy®”. Why is this happening? Maria: The problem is that this drug was not meant for the masses, for all these young girls wanting to lose a few pounds for aesthetic reasons. It was meant for people with a BMI 30 or with a BMI 27 plus another comorbidity such as hypertension. Celebrities have brought attention to these drugs for weight loss, for example Ozempic has over 433 million views on TikTok. It has gotten so bad that people are turning to questionable sources online to purchase these drugs, where it is given cute names like “skinny shots.” And if your insurance does not cover Tirzepatide, it is still expensive, starting at around $1000 per month. Some of the insurers who used to cover the cost stopped covering it or placed new restrictions on who qualifies. Another downside is that tirzepatide and other drugs of this class have not been on the market that long, so the long-term effects are still not known. So far, early evidence shows that most people gain the weight back as soon as they stop taking it, so are the weight loss benefits sustainable at this high cost? Maria: We talked about the adverse effects in the last episode, but it’s important to go over them again. Patients can have diarrhea, nausea, vomiting, constipation, and abdominal pain that can often bring these patients into the clinic or even the Emergency room thinking they are ill, when in fact it is an adverse effect of their medication, especially the first few days of starting or increasing the dose. So, educating patients is very important before they start this new drug. There is also a small risk of pancreatitis or gallbladder problems, so it is important to have blood work done to check the pancreas and gallbladder prior to starting tirzepatide. There is also a warning to avoid using it if you have a family or personal history of thyroid cancer. Arreaza: Reminder, MEN type 1. I would like to mention the so-called “Ozempic face”. It is the face you get with rapid weight loss, making you look a little older due to fat loss on the face. As a summary, tirzepatide is a very effective medication for weight loss, pending FDA approval. It is not free of side effects, so we still need to follow the recommendations from FDA and other reputable sources to prescribe it responsibly. There is room for further research on these medications. Currently, there are no clear guidelines regarding labs before starting treatment (lipase?) or labs for monitoring after treatment. The evidence regarding these medications continues to evolve and we should stay up to date with the changes. _______________________Conclusion: Now we conclude episode number 142 “Tirzepatide II.” Future Dr. Beuca came back almost one year later to shed more light on the use of tirzepatide in the treatment of obesity. Dr. Arreaza provided some insight into the management of side effects and the potential harm of this novel medication. Overall, tirzepatide is effective and safe and may be the answer to many of our patients with diabetes and obesity. This week we thank Hector Arreaza and Maria Beuca. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Brownie, Grace. “The Problematic Arrival of Anti-Obesity Drugs.” Wired, 25 January 2023. https://www.wired.com/story/anti-obesity-drugs/Dockrill, Peter. “Experimental Drug Breaks Record for Weight Loss in Latest Clinical Trial Results.”ScienceAlert, 9 May 2022, https://www.sciencealert.com/experimental-drug-breaks-record-for-weight-loss-in-latest-clinical-trial-results.Frías, Juan P., et al. “Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes.”New England Journal of Medicine, 5 August 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519.Jastreboff, Ania  M., et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” New England Journal of Medicine, 21 July 2022, www.nejm.org/doi/full/10.1056/NEJMoa2206038.“Label as Approved by FDA. - Pi.lilly.com.”Mounjaro Prescribing Information, Lilly USA, LLC, May 2022, https://pi.lilly.com/us/mounjaro-uspi.pdf.Mounjaro. Prescribing Information. Lilly USA, LLC.  May 2022. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi“Surmount-1 Study Finds Individuals with Obesity Lost up to 22.5% of their Body Weight when Taking Tirzepatide.” 4 June 2022. https://diabetes.org/newsroom/press-releases/2022/surmount-1-study-finds-individuals-%20with-obesity-lost-up-to-22.5-percent-body-weight-taking-tirzepatide.Royalty-free music used for this episode: "Happy-Go-Lucky." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Episode 141: Adrenal Insufficiency BasicsFuture doctor Wilson explains how to recognize an acute adrenal insufficiency and explains how to treat it. Also, chronic adrenal insufficiency is explained. Dr. Arreaza adds comments about congenital adrenal hyperplasia.Written by Candace Wilson, MSIV, American University of the Caribbean. Comments by Hector Arreaza, MD.June 2, 2023.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: After having seen patients with adrenal insufficiency when I did a rotation in ICU, I saw how important it is to be able to recognize it quickly to ensure that patients receive appropriate treatment as quickly as possible. Arreaza: AI is adrenal insufficiency but also AI stands for Artificial intelligence, so we had the idea to ask Chat GPT what are the adrenal glands and this is what we got: “The adrenal glands are small endocrine glands located on top of each kidney. They are small in size, but they play a vital role in producing and secreting essential hormones.” (end of quote)Glucocorticoids play an important role in the mobilization of energy reserves by increasing gluconeogenesis, glycogen synthesis, protein catabolism, lipolysis, appetite, and insulin resistance. Each adrenal gland is composed of two main parts: the outer region called the adrenal cortex and the inner region called the adrenal medulla. These two regions have distinct structures and functions.” The adrenal cortex has three zones, Zona glomerulosa (mineralocorticoids, mainly aldosterone), Zona fasciculata (cortisol), and Zona reticularis (androgens). Mineralocorticoids are a class of steroid hormones produced by the Zona glomerulosa of the adrenal gland that influence electrolyte and water balance through modifying renal absorption of sodium and potassium.Definition of AI: AI is “inadequate functioning of the adrenal glands”. Adrenal gland hormones: glucocorticoids, mineralocorticoids, and sex hormones.Primary vs. secondary adrenal insufficiency.Candace: Primary adrenal insufficiency is caused either by the abrupt destruction of the adrenal gland or by progressive destruction/atrophy, whereas secondary adrenal insufficiency is due to conditions that impair the hypothalamic-pituitary-adrenal axis leading to decreased ACTH production. Causes of primary adrenal insufficiency includes autoimmune adrenalitis (which is the most common cause in the US); infectious adrenalitis (tuberculosis being the most common cause worldwide); adrenal hemorrhage; infiltration of the adrenal gland by tumors, amyloidosis, or hemochromatosis; adrenalectomy; cortisol synthesis inhibitors (such as rifampin, fluconazole, phenytoin, ketoconazole); 21B-hydroxylase deficiency; and vitamin B5 deficiency. Fluconazole is commonly used to treat pulmonary cocci (Valley Fever in our community). What about secondary causes?Causes of secondary adrenal insufficiency include sudden discontinuation of chronic glucocorticoid therapy; stress (such as infection, trauma, or surgery) during prolonged glucocorticoid therapy; and hypopituitarism. Clinical presentation of adrenal crisis.Adrenal insufficiency can present acutely or chronically with more insidious symptoms. We will first discuss the acutemanifestation of adrenal insufficiency, also known as adrenal crisis. In any patient who demonstrates vasodilatory shock, unexplained severe hypoglycemia, or unexplained hyponatremia whether or not the patient is known to have adrenal insufficiency, adrenal crisis should be considered a possibility. Adrenal crisis is a life-threatening emergency that requires immediate medical treatment and can occur in either primary or secondary adrenal insufficiency, though it is most common in patients with primary adrenal insufficiency. The main feature of adrenal crisis is shock, but patients may also have vague symptoms such as anorexia, nausea, vomiting, abdominal pain, weakness, fatigue, lethargy, fever, confusion, or coma. In patients with adrenal crisis from primary adrenal insufficiency, volume depletion and hypotension are the major clinical features, resulting from mineralocorticoid deficiency. In contrast, the patients with adrenal crisis from secondary adrenal insufficiency (which is an isolated glucocorticoid deficiency) will have hypotension secondary to decreased vascular tone without volume depletion.Treatment of adrenal crisis.Signs of an adrenal crisis should be recognized quickly, and management should be started as quickly as possible. When adrenal crisis is suspected, do not wait for laboratory results before initiating treatment as this is a life-threatening medical emergency. After all necessary laboratory tests have been collected (including serum electrolytes, glucose, routine measurement of plasma cortisol and ACTH) and IV access has been established, infuse 2-3L of isotonic saline or 5% dextrose in isotonic saline as quickly as possible and give bolus of hydrocortisone 100mg IV followed by 50mg IV every 6 hours or 200mg/24 hours as a continuous IV infusion for the first 24hrs. The answer to many endocrine emergencies is IV fluids, in this case, you also add hydrocortisone and mineralocorticoids.Alternative glucocorticoids if hydrocortisone is unavailable include methylprednisolone and dexamethasone. While patient is hemodynamically unstable, it is important to frequently monitor vital signs and serum electrolytes to avoid iatrogenic fluid overload. When the patient has stabilized, continue IV isotonic saline at a slower rate for 24-48 hours, and for patients with primary adrenal insufficiency, begin mineralocorticoid replacement with fludrocortisone 0.1mg orally daily when saline infusion is stopped. If there is concern for infectious precipitating cause of the adrenal crisis, perform an extensive infectious workup. Addison’s disease.Early symptoms of chronic adrenal insufficiency can be vague and nonspecific (such as fatigue, weight loss, and GI complaints), making the clinical diagnosis more difficult than acute adrenal insufficiency. Diagnosis must be confirmed with a thorough endocrine evaluation to determine the type and cause of the adrenal insufficiency, but treatment should be started before the diagnosis is established in acutely ill patients. Primary and secondary adrenal insufficiency shares some common clinical manifestations, such as fatigue, weight loss, anorexia, nausea, vomiting, abdominal pain, amenorrhea, diffuse myalgia, arthralgia, confusion, delirium, stupor, depression, psychosis, mania, anxiety, disorientation, and hallucinations.Clinical manifestations of indicative of primary adrenal insufficiency include orthostatic hypotension, salt craving, hyperpigmentation especially of areas not typically exposed to sunlight (such as palmar creases, mucous membrane of the mouth), vitiligo (though hyperpigmentation is more common), hypotension, and auricular calcifications. Lab findings.Laboratory results will show electrolyte disturbances (such as hyponatremia, hyperkalemia, and hypercalcemia), azotemia, normocytic anemia, eosinophilia, increased renin, normal anion gap metabolic acidosis, hypoglycemia, increased ACTH, low cortisol, low aldosterone, increased cortisol releasing hormone, and decreased DHEA-S.Clinical manifestations of secondary adrenal insufficiency is similar to those in primary adrenal insufficiency with the notable exceptions of: hypotension (which is less prominent than in primary AI), absence of dehydration, pale skin as opposed to hyperpigmentation. Laboratory results in secondary adrenal insufficiency will show normal aldosterone, sodium, potassium, and renin; decreased ACTH and cortisol; and increased cortisol-releasing hormone.Treatment of chronic adrenal insufficiency. Treatment of primary adrenal insufficiency focuses on replacing hypocortisolism with glucocorticoids and hypoaldosteronism with mineralocorticoids. In contrast, the treatment of secondary adrenal insufficiency focuses on the replacement of hypocortisolism with glucocorticoids without the need to supplement aldosterone. Short-acting glucocorticoids (such as hydrocortisone) are the preferred medication for treatment since they roughly mimic the normal diurnal rhythm. Intermediate-acting (such as prednisone or prednisolone) and long-acting glucocorticoids (such as dexamethasone) are acceptable alternatives, especially in patients who are non-compliant with multiple-day dose schedules or those with severe late-evening or early-morning symptoms, but due to variable inter-individual metabolism of dexamethasone, be cautious of over-treating patients. Whether the patient is receiving short-acting, intermediate-acting, or long-acting, ensure that patients receive the lowest glucocorticoid dose that relieves symptoms while avoiding signs and symptoms of glucocorticoid excess (such as weight gain, facial plethora, truncal obesity, osteoporosis, etc.).Summary: Primary = Glucocorticoids and mineralocorticoids. Secondary = Glucocorticoids. Glucocorticoids can be short, intermediate, and long-acting. What about mineralocorticoids?Fludrocortisone 0.1mg/day is the preferred agent for mineralocorticoid replacement in patients with primary adrenal insufficiency, though patients who are receiving hydrocortisone therapy in conjunction may require a lower dose of 0.05mg/day. Mineralocorticoid therapy may need to be increased during the summer due to salt loss in perspiration. As a reminder, aldosterone works by controlling the reabsorption of sodium and excretion of potassium. It influences water reabsorption. It is part of the renin-angiotensin-aldosterone system (RAAS) to maintain blood pressure. In addition, it is important that patients receive adequate education about their medical condition and causes, whether it is primary or secondary adrenal insufficiency, especially the maintenance of medication, adjustment during minor illnesses, and when to consult a clinician.Bottom line: Adrenal insufficiency can be acute or chronic, primary or secondary. In primary adrenal insufficiency, laboratory results will show electrolyte abnormalities, such as hyponatremia and hyperkalemia, with increased ACTH. Whereas in secondary adrenal insufficiency, electrolytes will be normal, and ACTH will be decreased. Both primary and secondary adrenal insufficiency require treatment with glucocorticoid, but a mineralocorticoid should be added in the setting of primary adrenal insufficiency. _________________________Conclusion: Now we conclude episode number 141, “Adrenal Insufficiency Basics.” We encourage you to recognize acute adrenal insufficiency promptly and start IV fluids and glucocorticoid stat. Candace reminded us that chronic adrenal insufficiency presents with vague and insidious symptoms, including hypotension, fatigue, weight loss, anorexia, hyperpigmentation of the skin, and even vitiligo. Make sure to include our colleagues from endocrinology if you have concerns.   This week we thank Hector Arreaza and Candace Wilson. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Nieman, L. K. (n.d.). Diagnosis of adrenal insufficiency in adults. UpToDate. https://www.uptodate.com/contents/diagnosis-of-adrenal-insufficiency-in-adults. Accessed June 2, 2023.Nieman, L. K. (2022, October 25). Clinical manifestations of adrenal insufficiency in adults. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-adrenal-insufficiency-in-adults . Accessed June 2, 2023.Nieman, L. K. (2022a, October 19). Treatment of adrenal insufficiency in adults. UpToDate. Treatment of adrenal insufficiency in adults - UpToDate. Accessed June 2, 2023.Royalty-free music used for this episode: "Latina Havana Boulevard." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Episode 140: Bullous pemphigoid basicsFuture Dr. Stetkevych explains the diagnosis and treatment of bullous pemphigoid. She explains how to differentiate BP from pemphigus vulgaris. Dr. Arreaza added some comments and summaries.  Written by Katherine Stetkévych, MSIV, Ross University School of Medicine.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition. Bullous pemphigoid is an autoimmune condition in which the body produces antibodies against hemidesmosomes at the basement membrane of the skin. (Hemidesmosomes anchor the epidermis to the dermis.) As a result of this autoimmune reaction, inflammatory cells, and fluid fill under the epidermis, creating a blister.As a reminder, a vesicle is a collection of free fluid Presentation.Typically, bullous pemphigoid affects adults over the age of 60. We can say that it is a disease of elderly patients; the mean age of diagnosis is 80. There is no race or gender preference. The initial presentation is hives and pruritus. Patients may be itchy for ~10 months before the diagnosis. After patients have plaques, erythema, and itching, they have blisters. What is notable about the blisters in bullous pemphigoid is that the blisters are taut. They bulge out from the skin; however, they do not spread when pressure is applied laterally to the blister, and pressing on an unaffected skin area will not cause a new blister to form. The spread or creation of a blister with pressure is called the Nikolsky sign, and the fact that bullous pemphigoid is negative for the Nikolsky sign helps differentiate this condition from pemphigus vulgaris. Another notable feature is that the blisters of bullous pemphigoid are painless.If the blisters rupture, patients may experience short-term pain, but the erosion on the skin after the blisters rupture heal fast without scarring. Bullous pemphigoid typically does not involve the oral mucosa; however, there is a subtype that does. Nonetheless, should a patient present with bullae that involve the oral mucosa, it is important to test for the Nikolsky skin, determine whether the blisters are painful, and work up the blisters to determine the correct diagnosis.Diagnosis.The differential diagnosis is extensive and includes dermatitis herpetiformis, bullous systemic lupus erythematous, bullous drug eruptions, bullous impetigo, even insect bites, burns, erythema multiforme, and contact dermatitis. You can find non-specific findings such as peripheral eosinophilia in 50% of the patients. Serum tests include pemphigoid antibodies ELISA: BP 180 and 230 autoantibodies, desmoglein (desmoglain) 1 and 3. To get to a definitive diagnosis, you need a skin biopsy for histology and immunofluorescence. Histology will show subepidermal cleavage and the presence of inflammatory infiltrate with eosinophils or neutrophils. The diagnosis will be confirmed by direct immunofluorescence (DIF). The biopsy should be taken from inflamed skin next to a blister with 2/3 of normal skin and 1/3 of inflamed skin. The sample can be transported in normal saline. Management.Bullous pemphigoid is treated with first-line topical high-potency corticosteroids, such as clobetasol. In cases of severe bullae, systemic corticosteroids or doxycycline may be prescribed. For patients with refractory bullous pemphigoid, the appropriate next step is to start biologic therapies.With treatment, the prognosis is generally good for bullous pemphigoid. Some patients have spontaneous remission of the disease within a few years; however, for many, the disease is chronic, with recurrence and remission over months to years. If left untreated, bullous pemphigoid is usually a chronic, progressive disease that may cause functional limitation. Mucous membranous pemphigoid, the subtype of bullous pemphigoid which involves mucous membranes, may potentially be life-threatening if it involves the airway.Pemphigus vulgaris. Pemphigus vulgaris is an autoimmune condition similar to bullous pemphigoid. In pemphigus vulgaris, autoantibodies attack desmosomes in the epidermis, specifically desmoglein. Desmoglein is a cadherin protein that holds cells within the spinous layers of the epidermis together. Autoimmune destruction of desmoglein causes blisters to form superior to the basement membrane.The average age of onset for pemphigus vulgaris is 40-60 years old. There is an increased prevalence of the disease in Ashkenazi Jewish, Indian, Southeast European, and Middle Eastern descent.Presentation.Because the basement membrane of the epidermis remains intact, and the protein responsible for cell-to-cell adhesion is destroyed by the immune system, bullae are easily formed. Thus, Nikolsky sign will be positive with pemphigus vulgaris—lateral friction on a blister will cause it to expand, and it may be possible to create new blisters by applying pressure to a normal-appearing area of skin. These blisters may rupture easily, leaving painful sores which may become infected. Additionally, the oral mucosa is frequently involved in pemphigus vulgaris, which helps distinguish it from bullous pemphigoid.So, if you have a patient with skin blisters, and Nikolsyky sig is positive, and the oral mucosa is affected, then you can tell that this patient probably has pemphigus vulgaris. Tell us about the diagnosis. Diagnosis involves taking a skin biopsy and examining it under immunofluorescence. Antibodies will be seen surrounding keratinocytes in a net-like pattern, which makes sense because desmoglein surrounds keratinocytes so that it can be attached to its neighboring keratinocytes. Histology of a skin biopsy may also be obtained, which will show a “row-of-tombstones” appearance along the inferior margin of the blister. This is because the so-called tombstones are the keratinocytes of the basement membrane, which remain anchored due to untouched hemidesmosomes.Treatment.Treatment is similar to that for bullous pemphigoid but more aggressive. Initial treatment includes a systemic glucocorticoid and rituximab; if rituximab treatment is not possible, mycophenolate or azathioprine may be substituted instead. For refractory cases, glucocorticoid, rituximab, and mycophenolate/azathioprine may be given at the same time. Once the disease has improved, the tapering of the glucocorticoid may be initiated. Due to the risk of infection, loss of fluid from disseminated blisters, and potentially life-threatening involvement of the airway, the prognosis is poor with pemphigus vulgaris if left untreated.In summary, bullous pemphigoid is a blistering, autoimmune disease that normally presents in elderly patients and does not involve the oral mucosa. The diagnosis may require a skin biopsy, and the treatment starts with topical steroids; for severe cases, you may need systemic steroids and antibiotics. Pemphigus vulgaris affects the oral mucosa, it presents in younger patients (40-60), and the treatment is more aggressive with systemic glucocorticoids and immunosuppressants. ___________________Conclusion: Now we conclude episode number 140, “Bullous Pemphigoid.” Katherine explained that bullous pemphigoid is an autoimmune disease that causes skin blisters more frequently in elderly patients. She then explained that pemphigus vulgaris is a similar disease but more serious, and it requires more aggressive treatment.   This week we thank Hector Arreaza and Katherine Stetkevych (pronounced as Stet-KE-vish). Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________Links:Leiferman, Kristin M. “Clinical Features and Diagnosis of Bullous Pemphigoid and Mucous Membrane Pemphigoid.” UpToDate, www.uptodate.com/contents/clinical-features-and-diagnosis-of-bullous-pemphigoid-and-mucous-membrane-pemphigoid. Accessed 23 May 2023. Hertl, Michael, and Shamir Geller. “Initial Management of Pemphigus Vulgaris and Pemphigus Foliaceus.” UpToDate, www.uptodate.com/contents/initial-management-of-pemphigus-vulgaris-and-pemphigus-foliaceus. Accessed 23 May 2023. Habif, Thomas P. Clinical Dermatology, 6th edition, 2016, Elsevier, Inc. Page 655.

Episode 139: What is PCOS      Future Dr. Salimi explains the pathophysiology, signs, and symptoms of PCOS. Diagnostic criteria and the basics of treatment are also discussed. Dr. Arreaza adds some comments about the treatment of obesity.  Written by Elika Salimi, MS3, Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Hello there! My name is Elika and I am a third-year medical student at Western University of Health Sciences. Today I will be talking to you about polycystic ovary syndrome AKA PCOS.Do you have a female patient in her reproductive years with irregular menstrual cycles, or no menstrual cycles at all? Is she unable to conceive a child? Did she have an unexpected diagnosis of diabetes? Does she have more acne than she would like, or has hair in unwanted or unexpected areas such as her chin?Does she have a hard time losing weight? If you answered YES to many of these questions, it is possible that your patient is suffering from polycystic ovary syndrome also known as PCOS, which is one of the most common endocrine disorders in women. Pathophysiology:The exact pathophysiology behind this syndrome is unknown; however, per the American College of Obstetricians and Gynecologists committee, some studies have shown a strong association between PCOS and obesity. In a woman with obesity disorder, the excess adipose tissue ends up increasing peripheral estrogen synthesis and as a result, there is a decrease in peripheral sensitivity to insulin which means many of these women tend to have hyperinsulinemia. To be more detailed, it is important to mention that during these anovulatory cycles, the increase in estrogen, which is also unopposed estrogen with a lack of progesterone, can lead to endometrial hyperplasia and consequently increase the risk of endometrial carcinoma.Clinical Features: Unless there is a clear history and physical or if perhaps there was an incidental ultrasound finding of polycystic ovaries, the diagnosis of PCOS is not exactly black-and-white. That is why it is important to increase awareness so that women can put the pieces of the puzzle together and come in to get evaluated. Multiple cysts in ovaries can present in patients without PCOS, and they are common in teenagers. To use the multiple cysts as part of the diagnosis, the patient has to be 2 years after menarche (AAFP). Some of these clinical symptoms typically start during adolescence displaying menstrual irregularities such as she could’ve had her period and then stopped getting it or she has a very delayed onset of her menstrual cycle. It is also possible to have spotty menstrual cycles also known as breakthrough bleeding or menorrhagia. And very important to many women, she could be infertile or have difficulties conceiving.She could also have diabetes because of insulin resistance that comes with the metabolic syndrome that develops with PCOS, which is also increased if she has obesity. This obesity disorder going hand in hand with the metabolic syndrome, can also increase the risk of having sleep apnea, which could affect the quality of her sleep, finding herself more fatigued than she should be after adequate hours of rest. Other symptoms include skin conditions such as hirsutism which is basically male pattern hair growth in women in areas such as the upper lip, chin, around the umbilicus, back, or even buttocks. She could also have male pattern hair loss on the head or too much acne or oily skin or acanthosis nigricans which are these brown/velvety hyperpigmented streaks on the neck or axilla, or groin. She could also find herself more depressed or anxious.Diagnosis:The diagnostic criteria and treatments are mainly addressed in the Journal of Clinical Endocrinology & Metabolism, an evidence-based guideline for the assessment and management of polycystic ovary syndrome, and the American Family Physician Journal:The diagnosis of PCOS requires the presence of at least two criteria that are not due to any other endocrine disorder such as thyroid disease or hyperprolactinemia, or other. 1) Periods of oligo-ovulation and or anovulation which means she’s either having very low ovulatory cycles or she’s not ovulating at all. 2) hyperandrogenism and this could be based on her clinical features or laboratory studies showing elevated testosterone levels or LH to FSH ratio and 3) Seeing enlarged and/or polycystic ovaries on a pelvic ultrasound. This means that the pelvic ultrasound shows an ovarian volume of equal to or greater than 10 mL and/or there’s multiple cystic follicles that are about 2 to 9 mm in one or both of her ovaries which also usually tend to have a string of pearls appearance.So, if you have 2 out of the 3, you have PCOS. There are ways to confirm that there is in fact hyperandrogenism by doing lab studies and this could mean that her testosterone levels are elevated, or her androstenedione is elevated as well as elevated dehydro-epi-androsterone sulfate (DHEAS) and of course we need to rule out pregnancy and other endocrine disorders as I mentioned earlier. However, if the clinical picture of hyperandrogenism is there then that fulfills the diagnostic criteria for PCOS even if the serum antigen levels are normal. This also applies to an elevated LH:FSH ratio of typically greater than 2 to 1 which is also a characteristic finding of most patients with PCOS but this is not exactly necessary for diagnosis. We also don’t need to find cystic follicles in order to diagnose PCOS. Treatment: In family medicine practices and even OB/GYN practice for PCOS the most common recommendation for all patients is to encourage them to increase their physical activity (exercise) and eat healthy and try to consider behavioral modifications to have a target BMI of ideally less than 25 kg/m² because this can reduce estrone production in adipose tissue.Then we are thinking about ways to treat patients who are not planning to conceive versus those that are. For those patients that are not planning to conceive the goal is to regulate their menstrual cycles and irregularities as well as their hyperandrogenism and to treat the comorbidities as well to overall improve their quality of life.The first line treatment for hyperandrogenism to try to regulate menstrual cycle abnormalities is combined oral contraceptives also known as birth control pills. This also reduces endometrial hyperplasia which in turn can decrease the risk of endometrial carcinoma as mentioned earlier and it can reduce menstrual bleeding and you can reduce acne and try to assist with the hirsutism as well. As mentioned earlier, PCOS can also go hand-in-hand with insulin resistance or hyperinsulinemia and therefore we can also use metformin that can improve menstrual irregularities but also address the metabolic side of this as well. Summary: Diet, exercise, combined oral contraceptives, and metformin.Some other more controversial medications to treat hyperandrogenism could be potassium-sparing diuretics such as spironolactone that also inhibits 17-a-hydroxylase or finasteride which is a 5-alpha-reductase inhibitor and flutamide which is an androgen receptor blocker. The mentioned examples are typically for those people that can’t really tolerate combined oral contraceptives. Other things to consider for those that are suffering from obesity syndrome are to possibly consider bariatric surgery if of course the criteria are met, and this is on a case-by-case basis. Bariatric surgery may be an answer to many of our metabolic problems that’s why it is now called metabolic surgery. For patients who are planning to conceive the goal is to manage their comorbidities such as weight loss but also to try to induce ovulation.Now the first-line therapy for inducing ovulation is a medication called letrozole which is an aromatase inhibitor that in turn reduces estrogen production stimulating FSH secretion and ultimately inducing ovulation, not to get too heavily into the weeds of how these medications work, but basically it improves pregnancy and live birth rate outcomes in patients who are infertile because of the fact that they have anovulatory cycles or a.k.a. they are not ovulating.Then we also have clomiphene which is just an alternative to letrozole and has a different mechanism of action but it also stimulates ovulation by more particularly causing a pulsatile secretion of GnRH and in turn increasing FSH and LH as well, and this medication might be actually preferred over metformin monotherapy in women that are suffering from obesity syndrome who also have anovulatory infertility. However, apparently, clomiphene can cause more chance of multiple gestations versus letrozole.Also, letrozole is preferred over clomiphene to induce ovulation because of a higher rate of live births, but we have the risk of multiple pregnancies with both these methods. Let’s talk about the second-line therapies.As mentioned earlier we have this 2 to 1 ratio of FSH to LH in women with PCOS or at least a good amount of them. We said that that is not required to diagnose this disorder but we can also give women exogenous FSH plus human menopausal gonadotropin, but this is really a second-line treatment for ovulation induction and typically we go for second-line treatments if first-line therapies aren’t successful. But I will mention that using this exogenous gonadotropin is very expensive and it requires you to have access to specialized healthcare facilities and constant ultrasound monitoring so this may just not be feasible for many people but if you have the resources and it’s affordable for you then exogenous gonadotropins are actually preferred over clomiphene and metformin therapy.Metformin can also use as a second-line monotherapy for fertility treatments and this in combination with clomiphene can increase pregnancy rates, especially in women who are suffering from obesity disorder, and of course, this is first-line therapy for insulin resistance.Now if we’re talking about an invasive type of procedure for infertility it would be laparoscopic ovarian drilling which basically, we use a laser beam or surgical needle to reduce ovarian tissue to decrease its volume and try to reduce androgen production. Doing this can cause a hormone shift that can induce FSH secretion and ultimately improve ovarian function as well. This is also a second-line treatment for ovulation induction, but it can be performed as a first line if other indications for laparoscopy are present. Third-line therapy would be in vitro fertilization which means that basically we take mature eggs from ovaries and then we fertilize them with sperm in a lab and then the fertilized egg or the embryo is transferred to a uterus to be implanted.For the management of hirsutism, the first-line therapy is usually non-pharmacological and that’s electrolysis or light-based hair removal with laser or photo-epilation. For acne, we can consider benzoyl peroxide or topical antibiotics if necessary.Final thoughts: Now I know that was a ton of information but ultimately, we are trying to make women more aware of PCOS and let them know that they are not alone, also we are trying to reduce complications such as cardiovascular problems, diabetes, endometrial cancer, infertility or even pregnancy loss. The best we can do is try to educate more women because many are suffering from this condition and they have no idea. Again, my name is Elika Salimi, and I am a third-year medical student. If you have any questions, you can reach me at [email protected].___________________________Conclusion: Now we conclude episode number 139, “What is PCOS.” Future Dr. Salimi explained that patients with Polycystic Ovary Syndrome present with: Hyperandrogenism, Oligo-ovulation or anovulation, and multiple cysts in ovaries. If your patient meets 2 out of the 3 criteria, then you can confidently give the diagnosis of PCOS. Dr. Arreaza reminded us that by treating obesity you are also treating PCOS. This week we thank Hector Arreaza and Elika Salimi. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology..ACOG Practice Bulletin No. 194: Polycystic Ovary Syndrome..Obstet Gynecol.2018; 131(6): p.e157-e171.doi:10.1097/AOG.0000000000002656Hoeger KM, Dokras A, Piltonen T.Update on PCOS: Consequences, Challenges, and Guiding Treatment.The Journal of Clinical Endocrinology & Metabolism.2020; 106(3): p.e1071-e1083.doi:10.1210/clinem/dgaa839Williams T, Mortada R, Porter S.Diagnosis and Treatment of Polycystic Ovary Syndrome..Am Fam Physician.2016; 94(2): p.106-13.pmid: 27419327.Legro RS, Arslanian SA, Ehrmann DA, et al.Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab.2013; 98(12): p.4565-4592.doi:10.1210/jc.2013-2350.International evidence-based guideline for the assessment and management of polycystic ovary syndrome 2018.https://www.monash.edu/__data/assets/pdf_file/0004/1412644/PCOS_Evidence-Based-Guidelines_20181009.pdf 

Episode 138: SGLT-2 Inhibitors in heart failureFuture doctor Enuka explains the use of sodium-glucose-linked cotransporter-2 inhibitors (SGLT-2 inhibitors) in heart failure. Dr. Arreaza adds his experience with these medications and emphasizes their role as an effective treatment for type 2 diabetes.  Written by  Princess Enuka, MSIV, Ross University School of Medicine. Editing by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Intro:Heart failure is a major medical condition that affects millions of people worldwide. It is one of the leading causes of hospitalization and death in developed countries. Recently, SGLT2 inhibitors have emerged as a promising treatment option for heart failure. Today, we will discuss their benefits, their effectiveness, and their adverse effects.SGLT2 inhibitors, also known as sodium-glucose-linked cotransporter-2 inhibitors, are a relatively novel class of drugs that have shown promise in heart failure treatment. This transporter reabsorbs glucose from the glomerular filtrate back into the bloodstream. Under normal circumstances, SGLT-2 reabsorbs 100% of the filtered glucose unless it is saturated (as in hyperglycemia) or blocked by medications. SGLT2 inhibitors increase the amount of glucose excreted in the urine, which leads to blood glucose reduction. Examples include empagliflozin, dapagliflozin, and canagliflozin.SGLT-2 inhibitors have become a first-line therapy for diabetes mellitus. I heard before that it was used in Europe for T1DM, but it seems like they are no longer used, according to my most recent review of articles. SGLT2 inhibitors are not approved by the FDA for use in type 1 diabetes due to the risk of DKA. Princess, besides the benefits in diabetes, what else did you find in your review?Benefits/Efficacy:SGLT2 inhibitors have additional benefits beyond their glucose-lowering effects. One of the benefits of SGLT2 inhibitors is their ability to increase myocardial energy production, alleviate systemic microvascular dysfunction, and improve systemic endothelial function. Natriuresis and glucosuria mediated by SGLT2 inhibitors have been shown to lower cardiac pre-load and reduce pulmonary congestion and systemic edema, which is beneficial for heart failure management.Studies have shown that these drugs can also improve cardiovascular outcomes in patients with heart failure with a reduced ejection fraction. Some studies:The EMPEROR-Reduced trial demonstrated that empagliflozin, brand name Jardiance®, reduced the risk of cardiovascular death and hospitalization for heart failure in patients with reduced ejection fraction by 25% compared to placebo. Several clinical trials have also shown that this result is significant whether patients have type 2 diabetes or not. Also, in a multicenter, double-blind, randomized, placebo-controlled trial in patients with heart failure, treatment with dapagliflozin, brand name Farxiga®, improved heart failure-related symptoms and physical limitations after only 12 weeks of treatment. Patients treated with dapagliflozin had a significant, clinically meaningful improvement in the 6-minute walking test distance. The magnitude of these benefits was statistically and clinically significant, spanning all subgroups categorized. This included patients with and without type 2 diabetes and those with an ejection fraction above or below 60%.Anecdote:During a previous clinical rotation, I had a patient taking Jardiance for heart failure. He also had a history of chronic kidney disease and managed his condition well with medications and regular follow-ups. Interestingly, he was prescribed Jardiance®, which I initially believed was solely for diabetes management. When I asked him about it, he explained that his cardiologist prescribed Jardiance specifically for his heart. At the time, I did not understand the rationale behind prescribing Jardiance®, especially since the patient did not have type 2 diabetes. But after researching the medication, I figured that his cardiologist had chosen Jardiance® due to its demonstrated benefits in reducing the risk of cardiovascular death and hospitalization for heart failure. Although initially considered to be only glucose-lowering agents, the effects of SGLT2 inhibitors have expanded far beyond that. Their use has expanded to include heart failure and chronic kidney disease, even in patients without diabetes. It is, therefore, essential that cardiologists, diabetologists, nephrologists, and primary care physicians are familiar with this drug class.Adverse effects:It is worthwhile to note that SGLT2 inhibitors are not typically used as first-line treatment for heart failure, and not all patients with heart failure are appropriate candidates for these medications. SGLT2 inhibitors are generally well-tolerated, but they can cause adverse effects. Genital and urinary tract infections and euglycemic diabetic ketoacidosis are the most common side effects experienced by patients. The incidence of these adverse effects is generally low and can be managed with appropriate monitoring and treatment. In addition, SGLT2 inhibitors can also cause dehydration, electrolyte imbalances, hypotension, and acute kidney injury (AKI). These imbalances are more common in elderly patients or those with renal impairment, like the patient I discussed earlier. Genital yeast infections: Diabetes is also a risk factor for genital yeast infections because glucose in the urine is used as a substrate by microorganisms to grow in the GU tract. UTI and genital yeast infections are prevented by staying well hydrated while taking these meds. Increased intake of water will dilute the urine and decrease the concentration of glucose in urine. UTI/genital yeast infections are treated as usual, and the SGLT-2 can be resumed after infections are treated. In case of recurrence, the clinician may consider discontinuation of medication based on a case-by-case assessment. Patients using SGLT2 inhibitors for treatment should have regular follow-ups with their physicians for the early detection of adverse effects. Bladder cancer: It is not clear if chronic glucosuria is tumorigenic since there are no long-term data. In clinical trials, 10 cases of bladder cancer were diagnosed among dapagliflozin users, five of which occurred only in the first six months of treatment. The FDA has recommended postmarketing surveillance studies. Dapagliflozin is not recommended in patients with active bladder cancer. Bone fractures and limb amputation: One trial (CANVAS) demonstrated an increased incidence of bone fractures and limb amputations among users of canagliflozin, but another trial (CREDENCE) did not demonstrate such an increased incidence of bone fractures or limb amputations. This increased risk has not been proven with empagliflozin. Summary: SGLT2 inhibitors have shown promise in heart failure treatment, particularly in patients with a reduced ejection fraction. Even though the specific mechanism of action through which they work on the cardiovascular system is currently unknown, they have been shown to reduce the risk of hospitalization for heart failure and cardiovascular death in several clinical trials. These medications lower blood glucose levels and have other beneficial effects on the cardiovascular system that make them good options for the management of heart failure.____________________Conclusion: Now we conclude episode number 138, “SGLT-2 inhibitors in heart failure.” Princess explained that SGLT-2 inhibitors have many benefits that go beyond their glucose-lowering properties. Recently, the use of SGLT-2 inhibitors has been extended to include heart failure with reduced ejection fraction and chronic kidney disease, even in patients without diabetes. Dr. Arreaza also explained that FDA has not approved the use of SGLT-2 inhibitors for the treatment of type 1 diabetes because of the reported increased risk of diabetic ketoacidosis or DKA. There is ongoing research about additional uses of SGLT-2 inhibitors, and we are looking forward to hearing more about these medications in the future.This week we thank Hector Arreaza and Princess Enuka. Audio editing by Adrianne Silva.Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you. Send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _________________Links:Packer M, Anker SD, Butler J, et al. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383(15):1413-1424. https://pubmed.ncbi.nlm.nih.gov/32865377/Cosentino F, Grant PJ, Aboyans V, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J. 2020;41(2):255-323. https://pubmed.ncbi.nlm.nih.gov/31497854/Heerspink HJL, Perkins BA, Fitchett DH, et al. Sodium glucose cotransporter 2 inhibitors in the treatment of diabetes mellitus: cardiovascular and kidney effects, potential mechanisms, and clinical applications. Circulation. 2016;134(10):752-772. https://pubmed.ncbi.nlm.nih.gov/27470878/Zelniker TA, Braunwald E. Mechanisms of cardiorenal effects of sodium-glucose cotransporter 2 inhibitors: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(4):422-434. https://pubmed.ncbi.nlm.nih.gov/32000955/Nassif, M. E., et al. (2020). The SGLT2 inhibitor dapagliflozin in heart failure with preserved ejection fraction: A multicenter randomized trial. Nature Medicine, 27(11), 1954-1960. https://doi.org/10.1038/s41591-021-01536-xRoyalty-free music used for this episode: "Tempting Tango." Downloaded on October 13, 2022, from https://www.videvo.net/

Episode 137: Heart Transplant and LVADFuture Doctor My explains two treatments for advanced heart failure, heart transplant and Left Ventricle Assist Device (LAVD). Dr. Arreaza adds historical information about the first artificial heart implant and the first LAVD.  Written by My Chau Nguyen, MSIV, American University of the Caribbean School of Medicine. Comments by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Introduction: Advanced heart failure is a major concern in the United States. Heart failure has a high 1-year mortality average of 33%. Although medical therapies have improved survival rates, some patients with progressive and advanced heart failure may still require heart transplantation or mechanical support such as left ventricular assist devices (LVADs) to prolong survival and improve quality of life.It is estimated that 23 million people in the world have heart failure, and many of them are in end-stage heart failure. When it comes to treating severe heart failure, there are two main options: heart transplantation and left ventricular assist devices (LVADs). Heart transplant: The operation to perform a heart transplant typically lasts between five to six hours but may take longer in patients who have undergone previous open-heart surgery or have an LVAD in place. However, because donors’ hearts are a scarce resource, not all patients are eligible for transplantation. The following are absolute indications for referral for Heart Transplant listing:Cardiogenic shock requiring continuous intravenous inotropic therapy (i.e., dobutamine, milrinone, etc.) or circulatory support with intra-aortic balloon pump counterpulsation devices or left ventricular assist device (LVAD) to maintain adequate organ perfusion.Peak oxygen consumption VO2 (VO2max) less than 10 mL/kg per minute.New York Heart Association NYHA class III or IV despite maximized medical and resynchronization therapy.Recurrent life-threatening arrhythmias unresponsive to medical therapy such as an implantable cardiac defibrillator, medical therapy, or catheter ablation.End-stage congenital heart failure with no evidence of pulmonary hypertension.Refractory severe angina without potential medical or surgical therapeutic options.Selected patients with restrictive and hypertrophic cardiomyopathies.My experience with a heart transplant: I consider myself extremely fortunate for witnessing the whole complex procedure involved in lung and heart transplantation at Jackson Memorial Hospital in Miami, FL. It was an incredible experience to join the transplant team in retrieving a donor organ. Timing plays a critical role in heart transplants. When a suitable donor becomes available, every second counts. We must quickly arrange transport and secure an operating room. It is essential that the distance between the donor and the hospital is within our designated region. For example, we are in Region 5, including Arizona, California, Nevada, New Mexico, and Utah. Once everything is in order, we divide into two teams. One team sets off to retrieve the donor while the other prepares the patient in the operating room. It is a race against time, as hearts and lungs must be transplanted within approximately four hours of removal from the donor. It was remarkable to see how everything was so precisely scheduled, from the arrival and departure of the teams to the transplantation of the organs. It is an inspiring experience to witness these life-saving procedures in action.History of the artificial heart.Arreaza: It is great to hear about your experience, but we know that not everyone can have a heart transplant. So, let us talk about other options. For example, an artificial heart. I lived in Utah for several years and I heard something about the first artificial heart being implanted there, so here is the information. William DeVries was the surgeon who led the implantation of the first artificial heart, the Jarvik-7, at the University of Utah on December 1, 1982. The patient was a retired dentist, Barney Bailey Clark, who survived 112 days connected to the device. Today, the modern version of the Jarvik-7 is known as the SynCardia temporary Total Artificial Heart. It has been implanted in more than 1,350 people as a bridge to transplantation.Left Ventricular Assist Device (LVAD):In recent years, LVADs have become increasingly popular as a viable alternative to transplantation, as they have demonstrated improved durability by using wear-free components, greatly improving mortality rates in heart failure patients. Arreaza: The first left ventricular assist device (LVAD) system was created by Domingo Liotta at Baylor College of Medicine in Houston, Texas, in 1962. It is basically a pump that is used for patients who are on end-stage heart failure. The LVAD is surgically implanted, it is a battery-operated pump that helps the left ventricle pump blood to the rest of the body. LVADs can be used as a temporary treatment while patients are waiting for a transplant. It is called a “bridge-to-transplant therapy”. In some cases, an LVAD may restore a failing heart and eliminate the need for a transplant. An LAVD may also be used as a “destination therapy” in patients who are not candidates for heart transplants. LVAD can prolong and improve patients' quality of life.My: The purpose of an LVAD is to support patients with heart failure by increasing perfusion and reducing filling pressures in the heart. It is important to note, however, that LVADs only partially assist the pumping action of the diseased ventricle and cannot fully replace the function of the heart. Therefore, the decision to have an LVAD or heart transplant must be taken after careful discussion between the patient and the cardiologist to determine which option is best to reach the patient’s goals of care.Example of an LVAD:Recently, The Berlin Heart Ventricular Assist Device (VAD) has been a game-changer in saving children with severe heart conditions. As you may guess from the name, it is developed in Germany. It is recently approved by US FDA in 2011. This type of LVAD has been used in approximately 1,000 children worldwide, including 12 cases in the United States. The Berlin Heart is a simple air-driven pump that takes over the work of one or both sides of a child's own heart. It pumps blood around the body to keep the brain and other organs healthy, allowing the child to grow and get stronger. The use of this device is required until the child is transplanted, or for a small number of children until their own heart recovers. I once again had the privilege of witnessing the procedure performed by one of the inventors, my preceptor, Dr. Loebe in the NICU at Jackson Memorial Hospital.Conclusion: Now we conclude episode number 137, “Heart Transplant and LVAD.” My explained two options for the treatment of advanced heart failure: Heart transplant and Left Ventricular Assist Device, or LVAD. She shared her recent experience in her surgery rotation at Jackson Memorial Hospital. Dr. Arreaza added the history of the first artificial heart implanted in Utah and the first LAVD. We hope you enjoyed it.This week we thank Hector Arreaza, and future doctor My Chau Nguyen. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________Sources:Theochari CA, Michalopoulos G, Oikonomou EK, Giannopoulos S, Doulamis IP, Villela MA, Kokkinidis DG. Heart transplantation versus left ventricular assist devices as destination therapy or bridge to transplantation for 1-year mortality: a systematic review and meta-analysis. Ann Cardiothorac Surg. 2018 Jan;7(1):3-11. doi: 10.21037/acs.2017.09.18. PMID: 29492379; PMCID: PMC5827119. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5827119/.Alraies MC, Eckman P. Adult heart transplant: indications and outcomes. J Thorac Dis. 2014 Aug;6(8):1120-8. doi: 10.3978/j.issn.2072-1439.2014.06.44. PMID: 25132979; PMCID: PMC4133547. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133547/.Birks, E. J., & Mancini, D. (2022, November 9). Treatment of advanced heart failure with a durable mechanical circulatory support device. UpToDate. Retrieved April 21, 2023. https://www.uptodate.com/contents/treatment-of-advanced-heart-failure-with-a-durable-mechanical-circulatory-support-device.Drews T, Loebe M, Hennig E, Kaufmann F, Müller J, Hetzer R. The ‘Berlin Heart’ assist device. Perfusion. 2000;15(4):387-396. doi:10.1177/026765910001500417.Middleton, J. (2021, August 26). What is the time frame for transplanting organs? Donor Alliance. Retrieved April 21, 2023, from https://www.donoralliance.org/newsroom/donation-essentials/what-is-the-time-frame-for-transplanting-organs/.The Bridge to Transplant Team, The Child and Family Information Group. (2017, July). Berlin Heart Mechanical Heart Assist. NHS choices. Retrieved April 21, 2023, from https://www.gosh.nhs.uk/conditions-and-treatments/procedures-and-treatments/berlin-heart-mechanical-heart-assist/.Royalty-free music used for this episode: "Tempting Tango." Downloaded on October 13, 2022, from https://www.videvo.net/

Episode 136: Street Med 2.      Future Dr. Bedi presents the history and purpose of street medicine and shares why she became interested in this topic. Dr. Saito tells his personal experience and shares the particular challenges of unhoused patients.Written by Indudeep Bedi, OMS III, MSIII, Western University of Health Sciences. Comments by Steven Saito, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Indu: I want to talk about street medicine in some general terms, as well as Tracy Kidder's article published in the NYT this year, called "You have to learn to listen," which is based on Kidder's book Rough Sleepers, on Dr. Jim O'Connell's work with the Boston homeless community.  Dr. Saito: Let's start by talking about street medicine in general. What exactly is street medicine? Street medicine was a term coined by Dr. Jim Withers, from Pittsburgh, who has been practicing the art since the 90s. He founded the Street Medicine Institute (SMI) in 2009, which strives to connect providers worldwide to address homelessness. Providers practice healthcare, of course, but first and foremost, it is about building relationships and demonstrating you are one of them instead of the power differential that usually exists in our system. It requires a paradigm shift, and it's a shift in thinking. Dr. Jim Withers himself, for example, began to wear ragged clothes and put dirt in his hair to show these vulnerable individuals that he was accepting of who they were and respected them for it. In return, they respected him. Dr. Saito: Do you know of other programs which exist? There are a bunch of programs now that have spurred up, such as Doctors without Walls, San Francisco's community health center, of course, are very own CSV, and the Boston Pine Street shelter, which I will talk about more. The SMI publishes an annual report, and there are about 50 independent street medicine programs nationwide. Many global programs have sprung up, too. An international street medicine symposium was founded in 2005. In general, this is an excellent community of providers who can share best practices regarding this unique population. Even a student coalition at the SMI helps get student-run programs off the ground. Dr. Saito: What is one of the homeless community's biggest problems? That is a tricky question because of the complexity surrounding this issue. I will tackle this by answering that housing is one of the most considerable problems. The housing may be either transitional or permanent. Transitional operates to get the individual immediately off the street. In contrast, permanent housing takes longer to find, but many charities have bought real estate to create permanent housing. Permanent housing also includes the individual being vetted, in a lot of cases, to make sure that they will do okay if they have a place of their own. Are they able to be independent? Can they pay rent? Do they have a job? In 2009, however, a new program was implemented known as Housing First. This social program provided "a no-strings-attached" housing to the homeless population with substance use and mental health problems. What was great about this program is it was found that the relapse rate was much lower in this population when compared with other programs. In 2018, however, due to gentrification and rent increases, there was a very steep rise in homelessness in cities on the west coast, such as Seattle, San Francisco, and Los Angeles. To combat this, many state-wide programs were established that work with healthcare providers to provide these individuals with the help they need. Dr. Saito: What is the article "You have to learn to listen" about?I would first like to read a short excerpt from the article: "In American cities, visions of the miseries that accompany homelessness confront us every day — bodies lying in doorways, women standing on corners with their imploring cardboard signs dissolving in the rain. And yet, through a curious sleight of mind, we step over the bodies, drive past the mendicants, return to our own problems. O'Connell had spent decades returning, over and over, to the places that the rest of us rush by." Dr. O'Connell completed his IM residency at Mass General in Boston and was about to move on to an oncology fellowship when he was approached by some colleagues with a request to take a position as a physician for one year in a grant-funded program from the city of Boston to address homelessness in the 1980s. The program operated outside of Pine Street Inn homeless shelter. One of the initial experiences that Kidder describes Dr. O'Connell having was his first day of being there, being surrounded by stern-faced nurses who obviously knew more than he did about this niche population. He really had to prove himself to them and the individuals who were homeless. Soon after he joined, Dr. O'Connell met a nurse by the name of Barbara McInnis, who told him, "I really think we want doctors, but you've been trained all wrong. If you come in with your doctor questions, you won't learn anything. You have to learn to listen to these patients." Nurse McInnis also taught Dr. O'Connell a common practice at their shelter, which was to soak patients' feet by filling a tub and pouring in betadine, as a lot of the population did not have footwear. This reflection of "placing the doctor at the feet of the people he was trying to serve" is beautiful. That is precisely what street medicine is about. Dr. O'Connell has been managing the street medicine program at Pine Street since then, and that oncology fellowship remains forgotten. The program he is a part of now has 19 other shelters in order to tackle Boston's growing homelessness problem. However, it was apparent to Dr. O'Connell a few years in that these shelters were not really making a difference in terms of curbing the amount of homelessness. That problem was still continuing to grow. In addition, many other systemic issues were leading to the rise in homelessness, such as the AIDS epidemic around the time, lack of welfare programs, gentrifications, etc. But the difference was being made in the sense that these individuals who had been pushed to the margins, who were overlooked, and who were in essence burned by the healthcare system in one way or another and highly suspicious of providers for that reason, were now able to be coaxed into receiving and accepting the help they needed. This was done by, as said previously, placing the physician at the feet of the people he was trying to serve.Over the years, the program continues to grow and even created a new clinic with beds, offering housing vouchers, but it also faces other problems, such as funding and efficiency. A significant focus for the homeless community is housing options. And most people will do really well after being housed, while for others, finding housing brings more troubles with it when they need to be continuously moved from home to home to avoid eviction. I think a lot of it has to do with the lack of resources that come with housing. Homelessness is so complex that finding a home is simply not enough, and these individuals can again fall through the cracks if those other issues are not addressed. While street medicine does a lot of good, it is a harsh reality that individuals have a low life expectancy and will die of this homelessness because of the other issues that remain a constant in their lives, such as substance use, HIV, AIDS, and mental health issues. Dr. Saito: How did you come to be interested in this topic?I have been interested in street medicine for a while now. I volunteered in some projects that exposed me to the perils facing the population, especially for addiction. For example, I had an excellent opportunity to work with an organization that would put up tents to test the communities for HIV and connect them with resources if needed. We would specifically go to the areas where people who were homeless or of low SES tended to congregate. I really started to think about it more recently when I encountered a patient on the Infectious Disease service who was incredibly complex in an immunocompromised state due to AIDS, with multiple hospitalizations and pretty much every infection under the sun. He was what we commonly refer to as non-compliant because of substance use, and whenever we found placement for him upon discharge, he would run away from that home. I think, as providers, we are very quick to judge and label patients as non-compliant without pausing to understand the nuances of their condition. He would later continually return to the hospital in an acute exacerbation of his illness. With each hospitalization, his baseline continues to worsen. And I was deeply saddened to come across such a patient and also recognized within myself this frustration with the system in which we operate. I am a bit despondent about his outlook, and the work of the CSV team is critical to these rough sleepers. ____________________Conclusion: Now we conclude episode number 136, “Street Med 2.” Future Dr. Bide recounted the experience of Dr. O’ Connell and some of the challenges faced by our unhoused patients. Dr. Saito added his personal experience and reminded us that compliance with medications may be difficult in unhoused patients. Here in Clinica Sierra Vista, we are proud of our street medicine program, and we hope many more volunteers would join us in our mission to bring “health for all.”This week we thank Indudeep Bedi, Steven Saito, and Hector Arreaza. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Meyers, T. (2022) Understanding the practice of Street Medicine, Direct Relief. Direct Relief. Available at: https://www.directrelief.org/2022/02/understanding-the-practice-of-street-medicine/.Balasuriya, L. and Dixon, L.B. (2021) Homelessness and mental health: Part 2. The impact of housing interventions. Psychiatry Online. Available at: https://ps.psychiatryonline.org/doi/10.1176/appi.ps.72504.Atherton, I. and Nicholls, C.M.N. (2012) Housing first as a means of addressing multiple needs and homelessness. European Journal of Homelessness. European Observatory on Homelessness. Available at: https://dspace.stir.ac.uk/handle/1893/9035#.ZCRWKBXMKdY.Kidder, T. (2023) You have to learn to listen: How a doctor cares for Boston's homeless. The New York Times. Available at: https://www.nytimes.com/2023/01/05/magazine/boston-homeless-dr-jim-oconnell.html.Street Medicine Institute Annual Report (2021). Street Medicine Institute. Available at: https://stmi.memberclicks.net/assets/AnnualReport/Street%20Medicine%20Institute%202021%20Annual%20Report.pdf.Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Episode 135: Exercise in Diabetes    Kishan and Princess explain how exercise lowers or raises blood glucose levels in diabetes. Dr. Arreaza adds some comments about insulin resistance.  Written by Kishan Ghadiya, MSIV, Ross University School of Medicine. Comments by Princess Enuka, MSIV, Ross University School of Medicine; and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today is April 7, 2023. Ep. 135.Intro:It is widely known exercise is paramount for all individuals. The American Heart Association recommends at least 150 minutes of moderate-intensity exercise weekly for general health. Exercise is particularly important in patients with diabetes, who require extensive lifestyle modification to manage their sugar levels. However, it is not well known how glucose metabolism changes when patients with diabetes exercise.My patient in the clinic.I recently saw in the clinic a young patient newly diagnosed with type 2 diabetes who asked about how his exercise was helping his sugar levels. He was confused because he heard that exercising allows for better glucose control but complained that his sugar levels were higher after exercising.To understand what is going on in this patient, it is important to understand the underlying pathophysiology of diabetes. First off, the two most common types of diabetes are type 1 and type 2. Type 1 occurs when the pancreas stops producing insulin altogether. Type 2 occurs when the insulin secreted by the pancreas is no longer effective in normalizing blood sugar levels; the body is not able to utilize glucose efficiently, the number of calories consumed exceeds the body’s demands, and thus increasing body weight, which leads to insulin resistance and eventually pancreatic beta-cell exhaustion. Diabetes is thus a disease state of prolonged hyperglycemia and confers many long-term complications such as accelerated cardiovascular disease, neuropathy, nephropathy, and retinopathy.How does exercise lower blood glucose? Once patients are diagnosed with diabetes, management is lifelong, and it takes considerable mental and physical effort to manage this change in health. Exercise is a key metric in diabetic management because lowering blood sugar is as simple as using excess glucose to create energy in our muscles. There are two main mechanisms in how exercise has a positive effect on diabetes. The first mechanism is that exercise directly increases insulin sensitivity by enhancing the muscles’ ability to effectively respond to insulin, thus allowing for better use of insulin on board (IOB). This benefit is not only seen during exercise itself but also up to 24 hours after exercise is complete. This means many patients with controlled diabetes can see a euglycemic effect up to 1 day after exercise.The second mechanism is that increased glucose uptake into muscle does not require insulin secretion. In other words, active muscle use during exercise allows for glucose uptake even without the use of any insulin and is very effective in lowering blood sugar levels. Muscles have a higher metabolic rate than fat tissue. It means that even without exercising, a person with a higher muscle mass has a higher basal metabolic rate.What type of exercise would be the most effective in controlling blood sugar? The data is very clear that there is no relationship between exercise technique and glucose level, but there is a relationship between exercise intensity and glucose levels. In other words, patients wanting better blood sugar outcomes may choose whatever exercise regimen as long as they are able to do high-intensity exercise (i.e., resistance training, strength training, High-intensity interval training, HIIT).Anaerobic vs. aerobicBlood sugar levels during exercise will be different based on the types of exercise patients choose. For example, high-intensity anaerobic exercise (such as weightlifting) causes large spikes of blood sugar because the liver creates large amounts of glucose for anaerobic glycolysis. On the other hand, high-intensity aerobic exercise (such as running) confers lower blood glucose. Keep in mind both types of exercise confer excellent long-term patient outcomes, but the disparity in blood sugar is important to note as it can lead to confusion in patients that are very actively monitoring their sugar levels.Hyperglycemia after anaerobic exercise.So, returning to my patient mentioned above, further history revealed that he does weightlifting two or three times a week. Hyperglycemia would therefore be expected during and immediately after anaerobic exercise due to large amounts of glycolysis requiring the liver to create sugar. This patient’s increased blood sugar seen after exercising would not be a cause for concern as this is part of normal human body physiology.___________________________________Conclusion:  Now we conclude episode number 135, “Exercise in Diabetes.” Kishan explained that exercise improves insulin sensitivity and promotes muscle growth for improved glucose metabolism. Princess explained that anaerobic exercise may cause a transient rise in glucose while aerobic exercise causes glucose control over a longer period. Dr. Arreaza explained that insulin sensitivity is lost when we give frequent “high shots of sugar” to our body.This week we thank Hector Arreaza, Kishan Ghadiya, and Princess Enuka. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Kirwan JP, Sacks J, Nieuwoudt S. The essential role of exercise in the management of type 2 diabetes. Cleve Clin J Med. 2017 Jul;84(7 Suppl 1):S15-S21. doi: 10.3949/ccjm.84.s1.03. PMID: 28708479; PMCID: PMC5846677. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846677/Riddell M, Perkins BA. Exercise and glucose metabolism in persons with diabetes mellitus: perspectives on the role for continuous glucose monitoring. J Diabetes Sci Technol. 2009 Jul 1;3(4):914-23. doi: 10.1177/193229680900300439. PMID: 20144341; PMCID: PMC2769951. https://pubmed.ncbi.nlm.nih.gov/20144341/Zahalka SJ, Abushamat LA, Scalzo RL, et al. The Role of Exercise in Diabetes. [Updated 2023 Jan 6]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from  https://www.ncbi.nlm.nih.gov/books/NBK549946/Royalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/

Episode 134: Martian Medicine 101.    Future doctor Collins and Dr. Arreaza talk about the health risks of going to space and to Mars, especially the effect of radiation. Written by Wendy Collins, MSIII, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today is March 31, 2023.Arreaza: Wendy, I confess I am excited for today’s topic. My love for space began with E.T. (I know, I am old). I was exposed to that famous movie when I was a little kid, and ever since, I have had a tremendous curiosity about space and Mars. Honestly, I did not think this could be a topic for our podcast until I met you. Wendy: I got inspired to talk about space medicine because I want to go into this field. My college degree was in Physics, and I was fortunate to do Astrophysics and Particle Physics research as an undergraduate, as well as coral reef research. I am passionate about Medicine and treating patients, but I also love Aerospace Medicine because it’s so interdisciplinary. Flight surgeons get to scuba dive, work on oceanography, botany, engineering projects, and more, and collaborations like that sound exciting to me. Anyways let us talk about what is going on in the industry right now. Dr. Arreaza, do you know what humans are doing in space this year?Arreaza: I do! I like to watch the launches online and in person. I have seen several SpaceX rockets from my backyard (something I never imagined I could do), and there has been some big news, we are going back to the moon! Wendy: Yes! Artemis 1 was a successful unmanned mission to orbit the moon and it was launched in November and landed in December last year. Now we look to Artemis 2, which will be a manned lunar flyby. So, like Artemis 1, but with astronauts onboard. And the goal for future missions after that is to land on the moon, establish a lunar base, and eventually prepare us for a long-term space flight like that to Mars. And there is even a presidential order to land humans on Mars by 2033. Arreaza: Yes, it is very exciting! BUT there are many, many human health risks to space flight.Wendy: Even more for space flight outside of low earth orbit. Because of this, and because space flight is becoming commercialized, space medicine is a growing field, and growing in all medical specialties. Believe it or not, I was just in a talk by a NASA flight surgeon where it was mentioned that NASA is even looking for OB/GYN because 50% of their astronauts are women who need gynecological care, and they currently have to go off-site to receive it.Arreaza: That’s so cool! I’ve read of a handful of civilian and military aerospace medicine training programs for physicians after residency. And since we’re in Bakersfield and only a stone’s throw away from this campus, why don’t we briefly mention the University of California Los Angeles?Wendy: Yes, so UCLA established an aerospace fellowship very recently in 2021. That fellowship, unlike the rest of them, is actually for board-certified emergency medicine physicians only right now, I believe the only one that does not consider other specialties like internal medicine and family medicine, but the program is new so who knows that may change. The fellowship’s goal is to train the next generation of space flight surgeons. Part of the medical training includes working in arctic environments, Mars analog missions, which includes rotations at SpaceX and NASA’s jet propulsion laboratory. There are so many new avenues to pursue education and jobs in aerospace medicine but today we’re focusing on some research that’s near and dear, and revolves around how we get to Mars in one piece. You may ask, what are the health risks of going to Mars? Ultimately, I would like to chat about how we mitigate those risks, but first let’s define them.Arreaza: So, we got some ideas from a paper published in 2020 by Patel et al. It is titled: Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. Let’s begin.Wendy: Spaceflight is dangerous with unique risks and challenges. As a space flight surgeon, your job revolves around ensuring the overall safety of the crew, as well as their physical and mental health and well-being. The major health hazards include radiation, altered gravity fields, and long periods of isolation and confinement. Each of these threats is associated with its own set of physiological and performance risks to the crew.Arreaza: But crews do not experience stressors independently, so it is important to also consider their combined impact. NASA’s Human Research Program researches over 30 categories of health risks astronauts can face with space flight.Wendy: Yes, but this article only discusses 4 of those categories, but don’t worry, they are the biggies, they are the “Red Risks.”Arreaza: So, what are Red Risks?Wendy: Red Risks are risks that are considered the highest priority due to their greatest likelihood of happening and because they are most detrimental to the crew’s health and performance, which impacts the success of the mission.Arreaza: There also exists “yellow” and “green” risks too, which of course are important, but less severe or less likely to occur than the Red Risks. Wendy: I just want to say I really like the title of this paper. Red risks for a journey to a red planet because Mars of course is red. Anyways as part of this paper, the “red risks” we are going to cover are space radiation health risks. This paper also covers spaceflight-Associated Neuro-ocular Syndrome, which is also known as SANS, behavioral health and performance, and inadequate food and nutrition. But today, we are only going to cover radiation health risks. But one thing this article did not discuss was the human health risk of infection, so let’s briefly mention it now. Arreaza: Yes, I can imagine spacecrafts are not sterile environments. It would be important to mitigate infections and hygiene necessities and have antibiotics that are functional and not expired or altered by radiation. Alright let’s start with the first health risk on the list, radiation.Wendy: Space radiation health risk is a large topic because it does not just predispose you to cancer, it also affects many organ systems. So, we are going to break down the health risks caused by space radiation exposure into of course radiation carcinogenesis, but also cardiovascular disease, degenerative tissue effects, and lastly acute in-flight as well as late central nervous system effects. Arreaza:Wendy: Yes the spacecraft does filter some radiation of course, but not Earth’s atmosphere. It’s actually a common misconception that astronauts on the International Space Station are protected by Earth’s atmosphere. But it’s not the atmosphere, it’s Earth’s magnetosphere, which is protective from radiation on some level because it absorbs many high-energy protons from space that, if not absorbed, would interact and cause damage to whatever is around. Arreaza: But astronauts on the ISS are exposed to radiation, how much?Wendy: So, about one weekon the ISS is approximately equivalent to one year’s exposure to radiation on the ground. But astronauts going to Mars are going to be in space a lot longer than one week. NASA’s 2020 Perseverance rover mission took 7 months to get to Mars.Arreaza: And that’s without Earth’s magnetosphere, and not considering any travel back home. That’s a lot of radiation. How much radiation exposure would you get traveling to Mars?Wendy: The crew to Mars would be exposed to pervasive, low dose-rate galactic cosmic rays, and to intermittent solar particle events. Arreaza: Wow galactic cosmic rays?Wendy: Yeah, they sound cool but they’re not the ones that give us superpowers like in the Fantastic Four. It means high charge and high energy protons will come into contact with the spacecraft and all the things inside. While the spacecraft will act as a shield, it will never be an entirely perfect shield and protons will penetrate and interact with human tissues, and you know what that means Dr. Arreaza…Arreaza: DNA breaks which can cause diseases including cancer, cardiovascular and neurologic disorders. Wendy: Exactly. It’s important to note there are so many variables including the spacecraft design, what’s happening with the sun, and the duration of the trip. And because of all these things, the risk assessment for radiation exposure is difficult to pinpoint because it's truly going somewhere we’ve never gone before. The types of radiation encountered in space are very different from the types of radiation exposure we are familiar with here on Earth. There have been radiobiology experiments working on simulating space radiation here on Earth, but we still lack reliable human data.Arreaza: Interestingly, the astronaut with the longest space flight, a Russian physician astronaut Dr. Valeri Polyakov, was on the ISS for 437 days. Dr. Polyakov recently passed away. His cause of death is not disclosed, but he lived a long life into his 80s, so at least we know he did not get terminal cancer after all that time in space.Wendy: Yes, and that was just Dr. Polyakov’s longest flight. He was on five different Soyuz missions and 2 MIR missions. So, there will be radiation no matter what, what can be done about it?Arreaza: There’s ongoing research focused on age, sex, and health of the astronaut. Not all people are affected by radiation the same way. Biomarkers are being investigated to determine who will be less sensitive to radiation.Wendy: Exactly just like we have biomarkers to know if you are predisposed to developing cancers. But back to space.The major cancers of concern from space radiation are epithelial in origin, particularly lung, breast, stomach, colon, and bladder, and leukemias. Radiation is a “red risk” also because of the likelihood of developing cancer after the mission back on Earth. Dr. Polyakov was fortunate to live a long life, but what about our Mars astronauts with even greater radiation exposure?Arreaza: This research paper even mentions cancer is a long-term health risk and although it is rated as “red”, most research in this area is currently delayed. This is because NASA’s Human Research Program is focusing on in-mission risks, not the risks after the mission. But research is still being done to establish radiation dose thresholds, specifically permissible exposure limits. Wendy: So now let us talk about the effects of radiation that is not cancer.Arreaza: So, we know radiation can cause many other health problems. This includes cardiovascular and cerebrovascular diseases, cataracts, digestive and endocrine disorders, immune deficiencies, and respiratory dysfunction. Wendy: Specifically, we know cancer patients who have received high-dose radiation to the mediastinum, are at an increased risk for cardiovascular disease including heart attack and stroke. An astronaut who goes to Mars is more likely to die from a heart or vascular disease secondary to radiation than cancer.Arreaza: NASA also is concerned about the effects of other inflight risks such as more blood flow to your head without the effect of gravity. Not to mention developing atherosclerosis, myocardial infarction, stroke, or arrhythmia just like anybody else on Earth.Wendy: There is also chronic inflammation and increased oxidative stress from radiation, which contributes to cardiovascular disease. For example, the mechanism of increased endothelial dysfunction.Arreaza: Health problems are not only a result of spaceflight but there can be pre-existing conditions. Astronauts are extensively screened medically, but diseases can also arise in astronauts who are “healthy” before leaving. Wendy: Absolutely, which is why right now only extremely healthy individuals are candidates to become astronauts, although this will likely change as space becomes more accessible the more spaceflight commercializes.Arreaza: Other diseases induced by radiation include CNS effects. Acute CNS problems that may arise during flight are impaired cognitive function, motor function, and behavioral changes. These would cause serious problems for astronauts.Wendy: Besides acute, there are also chronic CNS problems. This includes Alzheimer’s disease, dementia, or accelerated aging. This has been shown with rodents exposed to radiation in which neurons and neural circuits change causing performance deficits.Arreaza: It is important to note that no astronauts have suffered from life-changing radiation damage illnesses to date.Wendy: Again, back to Dr. Polyakov is evidence of that. And again, more research needs to be done to understand the significance of radiation to human health and determine how much radiation is too much radiation.Arreaza: That was Martian Medicine 101. Why are we talking about space medicine in this podcast?Wendy: Space medicine might be an out-there topic for our Family Medicine podcast. But going into space has given us technologies that help us in our day-to-day in life for non-medical folks, but also for primary care staff. The aural thermometer that takes your temperature by being placed near your ear was developed by NASA. Also, ventricular assist devices LASIK, cochlear implants, and artificial limbs scratch-resistant lenses for glasses, are all works that have contributions from NASA. Anyways, radiation was a fun topic today, but stay tuned for Martian Medicine 102, coming soon when we will talk about the other health risks of going to Mars.____________________Conclusion: Now we conclude episode number 134 “Martian Medicine 101.” As you can see, family medicine is unlimited, in the future you may be working on Mars as a family doctor. An inquisitive future doctor, Wendy Collins, explained that radiation is one of the major risks of long space flights because besides cancer, radiation may also cause cardiovascular diseases, immune deficiencies, and respiratory problems. Dr. Arreaza reminded us that radiation does not affect everyone the same way and even though astronauts are screened extensively, at this point it is difficult to determine with precision who will be a perfect fit for space flights. Stay tuned for Martian Medicine 102.This week we thank Hector Arreaza and Wendy Collins. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! _____________________Links:Patel, Z.S., Brunstetter, T.J., Tarver, W.J. et al. Red risks for a journey to the red planet: The highest priority human health risks for a mission to Mars. npj Microgravity 6, 33 (2020). https://doi.org/10.1038/s41526-020-00124-6Royalty-free music used for this episode: Space Orbit by Scott Holmes, downloaded on July 20, 2022 from https://freemusicarchive.org/music/Scott_Holmes/. 

Episode 133: Neonatal JaundiceJennifer explained the pathophysiology of neonatal jaundice and how to treat it and described why screening for hyperbilirubinemia is important.    Written by Jennifer Lai, MS3, College of Osteopathic Medicine of the Pacific Western University of Health Sciences. Comments by Hector Arreaza, MD.  You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.What is neonatal jaundice? Jenni: Infant jaundice, also known as hyperbilirubinemia, is when there is a high level of serum bilirubin causing yellow discoloration of the newborn's skin and eyes. Bilirubin is a red-orange byproduct of hemoglobin catabolism that gives yellow pigment to skin and mucosa membranes. Arreaza: When we see jaundice on the eyes, it is actually the conjunctiva color we are seeing. So, the term “scleral icterus” should be changed to “conjunctival icterus,” but you may get corrected by unaware clinicians. Bilirubin actually binds elastin.What’s the pathophysiology/ big picture?Jenni: The key problem is the accumulation of high levels of bilirubin in serum and if left untreated, it can bind to tissues and cause toxicity. There are multiple reasons why there might be too much bilirubin in the serum. Excess bilirubin can be due to a benign normal condition, but it can also be due to a pathologic reason. It is important to differentiate between these two because the management and treatment can differ significantly. Arreaza: Highly bilirubin means that it is being either overproduced or under-eliminated. Physiologic jaundice Most of the time, hyperbilirubinemia is benign and physiologic, with yellowing typically occurring between 2-4 days. Normally, there is a period of transition caused by the turnover of the fetal red blood cells and the immaturity of the newborn’s liver to efficiently metabolize bilirubin and increased enterohepatic circulation. The most common reason is that the liver isn't mature enough to get rid of the bilirubin in the bloodstream or because the baby’s gut is sterile, so it does not have the bacteria to convert the bilirubin to get it out of the body. In general, newborns have a higher level of total serum or plasma bilirubin levels compared to adults for the following reasons: Newborns have more red blood cells (hematocrit between 50-60), and fetal red blood cells have a shorter life span (85 days vs. 120 days) than those of adults. After birth, there is an increased turnover of fetal red blood cells, so there is more bilirubin.Bilirubin clearance (conjugation and excretion) is decreased in newborns, mainly because of a deficiency of the hepatic enzyme UGT.Increase in the enterohepatic circulation of bilirubin as the amount of unconjugated bilirubin increases due to the limited bacterial conversion of conjugated bilirubin to urobilin.Pathologic JaundicePathologic jaundice includes severe neonatal hyperbilirubinemia, extreme neonatal hyperbilirubinemia, and bilirubin-induced neurologic disorders. We determine the severity of the jaundice using the total serum bilirubin (TSB). It is defined as a TSB >25 (severe) and TSB >30 (extreme). Other concerning signs include a TSB over the 95% percentile, a greater than 5mg/dL/day or 0.2mg/dL/hour, or jaundice that lasts for more than 2-3 weeks. Potential pathologic causes include but are not limited to: Increased bilirubin production from increased hemolysis which is when the red blood cells in the baby are being destroyed faster than normal, this can be due to blood group incompatibilities where the mom’s immune system starts to attack the baby’s red blood cells (such as Rh incompatibility) or from RBC membrane defects (spherocytosis).Birth Trauma when the head gets bruised after a vacuum or forceps is used to remove the baby from the vaginal canalInfection which prevents the bilirubin from being metabolized and excretedProblems with bilirubin clearance either from enzyme deficiencies such as Crigler-Najjar or Gilbert syndromeObstructed biliary systems causing bile to get stuck in the liverArreaza: Indirect bilirubin is the one elevated in newborns, but if you see direct hyperbilirubinemia, then you have to think of an obstruction.Jenni: Severe hyperbilirubinemia can cause brain damage. The amount of bilirubin and the duration of bilirubin ultimately determine the severity of the brain damage. This is because the bilirubin blocks some mitochondrial enzymes from being able to function properly, also it inhibits DNA synthesis/protein synthesis, and can cause DNA damage. This can ultimately lead to acute bilirubin encephalopathy which is described as 3 different phases: Phase 1 with poor feeding, lethargy, hypotonia, and seizures, Phase 2 with increased tone in extensor muscles causing neck contractions (retrocollis and opisthotonos), and Phase 3 with generalized increased tone. If the bilirubin encephalopathy persists it can also ultimately cause cerebral palsy, sensorineural hearing loss, and gaze abnormalities.  How and when do we treat? No phototherapy:The goal of treating jaundice is to safely decrease the amount of bilirubin in the body. Oftentimes babies with mild hyperbilirubinemia don't get any treatment and we just watch and wait. In premature babies, there is an increased risk for brain toxicity because a lower amount of bilirubin can result in brain toxicity. For these babies, it is important to ensure there is adequate breast milk to both prevent and treat jaundice because it helps the baby get rid of bilirubin through the stool and urine. Arreaza: Indirect sunlight exposure of the baby.Phototherapy:Other babies get phototherapy or more commonly known as light therapy. Phototherapy light treatment is when the baby’s skin is exposed to a special blue light which will help break down bilirubin and help with the excretion in stool and urine. The phototherapy should be continuous and placed on as much skin as possible and the treatment should be administered until bilirubin levels drop to a safe level based on the baby’s hour-specific thresholds. Arreaza: Home phototherapy is an option (UV blanket) available for rent or purchase.Phototherapy is very safe, however, with any treatment, there are risks and potential side effects. Some of these include skin rashes, loose stools, overheating, and dehydration. Occasionally, babies turn a dark gray-brown color in their skin and urine, but this is temporary and usually resolves on its own. While the baby is receiving phototherapy, it is important to continue breastfeeding to ensure appropriate fluid hydration, but in babies that cannot get enough breast milk, they may need to supplement with formula or even potentially start IV fluids. Benefits of screeningIt is therefore essential for universal bilirubin screening for all newborns prior to discharge to identify newborns who are at risk for developing severe hyperbilirubinemia. Hyperbilirubinemia is extremely common in newborns, with nearly all neonates having a higher total serum bilirubin than adults. The reason we screen is that this reduces the risk of developing severe hyperbilirubinemia and ultimately brain damage. This universal screening also then decreases hospital readmissions for neonatal hyperbilirubinemia. Arreaza: So, we check at 12-24 hours in a typical pediatric unit. We use a bilimeter (transcutaneous) and if we suspect it is not accurate, we do a serum bili. Be aware of the accuracy of bilimeters.How do we screen? We do this prior to newborn discharge through a transcutaneous bilirubin device (TcB) or lab total serum bilirubin (TSB). The bilirubin level is used with the assessment of risk for the development of severe hyperbilirubinemia. Newborn bilirubin screening guidelines include TSB or TcB within 24-48 hours after birth or before discharge. TcB is the noninvasive test, but TSB is the gold standard for assessing neonatal bilirubin. Newborns with visible jaundice in the first 24 hours should be concerned for severe hyperbilirubinemia. These babies should be screened earlier because of the risk of pathologic causes of jaundice. In addition to the bilirubin test, physicians will clinically assess by examining the skin under ambient or daylight to assess whether there is a yellow discoloration of the buccal, gingival, or conjunctival mucosa. Additionally, if a baby presents with scleral icterus, pallor, bruising, hepatosplenomegaly, or cephalohematoma (enclosed hemorrhage), these can be clinical presentations of neonatal jaundice. Follow up:After screening, we recommend that babies be closely monitored if jaundice does occur as it can be well managed with early treatment. A quick way to assess this at home is to press gently on the baby’s forehead and if the skin looks yellow where you press, it’s probably jaundice. If your baby doesn’t have jaundice, then the place where you pressed it should look lighter than normal. _____________________Conclusion: Now we conclude episode number 133, “Neonatal Jaundice.” Jennifer explained the pathophysiology behind the increased levels of bilirubin in babies. She reminded us that it is a physiologic process, but when the level of bilirubin is too high, then we need to start treatment. Treatments include indirect sunlight exposure of the baby, breastfeeding, and in some cases phototherapy, IV fluids, and even antibiotics and exchange transfusion in some cases. Dr. Arreaza reminded us of the importance of screening and monitoring “bili babies” in the clinic. This week we thank Hector Arreaza and Jennifer Lai. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at [email protected], or visit our website riobravofmrp.org/qweek. See you next week! ___________________Links:Episode 17: Why does bilirubin deposit in the eyes? – The Curious Clinicians, https://curiousclinicians.com/2021/01/20/episode-17-why-does-bilirubin-deposit-in-the-eyes/.Ansong-Assoku B, Shah SD, Adnan M, et al. Neonatal Jaundice. [Updated 2022 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532930/.Mayo Clinic. “Infant Jaundice – Symptoms and Causes.” Mayo Clinic, 2018, www.mayoclinic.org/disease-conditions/infant-jaundice/symptoms-causes/syc-20373865.“Newborn Jaundice.” Nhs.uk, 19 Oct. 2017, www.nhs.uk/conditions/jaundice-newborn/#:~:text=Jaundcie%20in%20newborn%20babies%20is.Preud’Homme D., “Neonatal Jaundice.” American College of Gastroenterology, Dec 2012, https://gi.org/topics/neonatal-jaundice/.Wong R., et al. “Risk factors, Clinical Manifestations, and Neurologic Complications of Neonatal Uncomplicated Hyperbilirubinemia.” Up to Date, Last Updated: Jan 5, 2023, https://www.uptodate.com/contents/risk-factors-clinical-manifestations-and-neurologic-complications-of-neonatal-unconjugated-hyperbilirubinemiaRoyalty-free music used for this episode: “Gushito - Burn Flow." Downloaded on October 13, 2022, from https://www.videvo.net/