Primary Care RAP

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD Paul Offit, MD is a world-renowned expert on the safety and efficacy of vaccines. He has authored over 160 articles, co-invented the rotavirus vaccine, and been featured on shows like “60 Minutes,” “The Daily Show,” and “The Colbert Report,” among many others. In this segment, Sol Behar, MD, and Neda Frayha,  MD pick Dr. Offit’s brain about why our patients may be skeptical about vaccines and how best to communicate with them for the safety and wellbeing of all our patients. Pearls: It is understandable that parents are questioning vaccines now given that they do not encounter the effects of these infections in their day to day life. The role of the clinician is to make the consequences of vaccine preventable diseases real for parents so that they can understand how truly scary they are.   Why might parents be skeptical of vaccines? Parents are no longer scared of the diseases that vaccines aim to protect children from. In comparison to the twenties and thirties, when children were dying from diphtheria or becoming disabled from polio, this generation of parents have not seen firsthand the effects of these infections. As practitioners, we are asking parents to vaccinate their children against 14 different diseases in the first year of life to prevent diseases that most people do not see, using biological fluids that most people do not understand. With these facts in mind, Dr. Offit underscores is reasonable it is for parents to be skeptical. What can practitioners do when faced with a vaccine skeptical parent? The first thing to do when you see someone who is hesitant about vaccines is to ask them what they are scared of. If there is a specific issue, be it autism, diabetes or multiple sclerosis, there likely will be data to answer those questions. As the clinician, you try to present the data in a compelling, passionate, and compassionate way. As Dr. Offit says, science alone is not good enough. It is also important to make people realize that the choice not to vaccinate is not a risk free choice. By referring to parent activist groups like Families Fighting Flu or National Meningitis Association, you can provide parents with examples of the very serious risk associated with not vaccinating. What is Dr. Offit’s approach to dealing with a parent that is unsure about vaccines? The way that Dr. Offit goes about it is as follows: he finds out what the parent is worried about, tries to go through how one would answer those question, he talks about what has been done to answer those questions and ends by emphasizing why it is important to vaccinate. He makes it personal, making sure that the parent knows that he has his own children that are fully vaccinated and says that vaccinating is a matter of loving the child. He tells parents that by not vaccinating their child, the parent is asking him to practice substandard care. Why might parents continue to believe that autism is linked to the MMR vaccine? As Dr. Offit explains, if you are a parent of a child that suffers from autism, you want to try and figure out why. What Andrew Wakefield offered was a reason why; in his explanation it was the vaccine that caused the development of autism. With this explanation, parents were allowed some control over the disease. For example, parents believed that they could control whether or not their future children developed autism but choosing not to vaccinate them. As practitioners we can say things like vaccines are good and vaccine protect against preventable disease but what we still cannot say is what causes autism and parents want that explanation. How can practitioners advocate for their patients? Say something. It is important for clinicians to speak up when they see misinformation being presented because these false claims are devaluing the truth of science.

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD   Rana Awdish, MD a pulmonary and critical care physician in Detroit, Michigan, wrote an incredibly powerful, bestselling memoir (In Shock) about her own experiences as a critical care patient. In this segment, she sits down with Neda Frayha, MD to talk about healing, the ways the giant medical education industrial complex contributes to provider burnout, and the redemptive power of connection. Pearls: Dr. Rana Awdish shares her story and takeaways from her experience as a patient that have changed how she practices medicine. A summary won’t do this justice - it’s a must listen!   Dr. Awdish’s medical story: She was in the final days of her training in pulmonary/critical care when she developed acute-onset abdominal pain while being 7 months pregnant. They assumed she had HELLP because her liver enzymes were in the 10,000’s, platelets were 15 and she was in hemorrhagic shock. It turns out that she had a ruptured hepatic adenoma, ended up losing the pregnancy, and went  into multiorgan failure in the surgical ICU. Some of her takeaways from that experience: She needed to be seen as a patient navigating an illness and having emotions about it Individual medical providers can have a profound impact on a patient’s experience during illness, both negatively and positively Providers often lose sight of the person immediately in front of us, caught up in things that are less patient-centric (ie: how many patients you have to see that day) Providers come in with an agenda without understanding what is important to the patient The medical education complex has a way of taking really idealistic and compassionate young people and often turns them into jaded cynics Part of this may be from a lack of modeling joy in work and a sense of purpose We often avoid hard conversations and leaning into the discomfort for the short-term benefit at the detriment of missing the long-term benefit Getting to know patients and tailoring your recommendations to their values is liberating as a provider Give yourself the permission to be the kind of providers our patients actually want us to be   References: Awdish R. In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. New York, New York: St. Martin’s Press; 2017.        

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at hippoed.com/PCRAPPOD Post-contrast AKI (or contrast induced nephropathy as it used to be called) is one of those hot-button issues in modern medicine. Is it really a thing? Was it ever, really? Neda Frayha, MD sits down with Salim Rezaie, MD of Rebel EM for an invigorating conversation about this controversial topic and what the literature actually tells us about it.    Pearls: The term contrast-induced nephropathy has fallen out of favor to post-contrast AKI because the debate about contrast’s role in kidney injury rages on. Much of the recent literature has not shown a difference in AKI for those who receive a CT with contrast. Earlier studies were based on contrasts of higher volume and osmolarity given arterially that are not routinely used today. Remember that studies excluded those who had a renal transplant, GFR4.   Terminology: contrast-induced nephropathy has fallen out of favor to post-contrast AKI because we aren’t sure if contrast is really the culprit Issues with the literature: Many studies involved high volume, high osmolar contrast given arterially, not venous, low volume or low osmolar contrast Early studies used 15,000 milliosmole contrast whereas today we are using 320-800 milliosmoles or even iso-osmolar contrast Shown that route does make a difference. People receiving arterial contrast (ie: coronary angiography) are more at risk of AKI Studies are observational so you cannot get to causation, just association Other potential risk factors: comorbid conditions (diabetes, heart failure, hypertension), volume depletion, concurrent medications (vancomycin, NSAIDs, diuretics) Are outcomes clinical or patient-oriented (ie: dialysis, death, increased length of stay) or a lab value change? New literature: 1. Annals of EM 2017 (Hinson et. al) Single center Retrospective cohort study 17,000 patients who underwent CT with contrast, without contrast or no CT at all Excluded if Cr > 4mg/dL or renal transplant Bottomline: no difference in patient-oriented outcomes (dialysis, mortality) 2. Annals of EM 2017 (Aycock et. al) Meta-analysis 28 articles with 100,000 patients Bottomline: no difference in patient-oriented outcomes (dialysis, mortality) 3. Lancet 2017 (AMACING trial) Randomized control trial (three parallel group, open label, non-inferiority) Excluded if GFR

This free iTunes segment is just one tiny snippet of the fully-loaded 3-hour monthly Primary Care RAP show. Earn CME on your commute while getting the latest practice-changing primary care information: journal article breakdowns, evidence-based topic reviews, critical guideline updates, conversations with experts, and so much more. Sign up for the full show at  hippoed.com/PCRAPPOD We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Devang Patel,MD joins Matt DeLaney, MD and Neda Frayha, MD for a conversation on CAP in general and the new guidelines in specific. Pearls: The latest guidelines for community acquired pneumonia now includes amoxicillin or doxycycline for 5-7 days as first-line treatment given the rising rates of macrolide resistance and less emphasis on coverage of atypical pneumonia pathogens.   Review of pathophysiology: Lower respiratory tract often preceded by an upper respiratory tract infection, that inhibits ability to clear mucus and pathogens invade the lungs Other risk factors: Smoking Elderly Immune compromise (ie: infection, steroids, cancer) Pathogens: Typical - strep pneumo, haemophilus, staph aureus Atypical (more common) - influenza, parainfluenza, mycoplasma, chlamydia pneumoniae, legionella, coccidioidomycosis (in the southwest) EPIC Study (2015) - study to determine pneumonia pathogens using all the tools we have available (culture, PCR) 62% no pathogen detected 22% viral - most were rhinovirus which does not cause lower respiratory tract infections but predisposes to pneumonia Strep pneumonia was the number one bacterial pathogen Bottomline: we still don’t know what causes most pneumonias but just that our patients get better with antibiotics Differentiating between typical v. atypical pneumonias - there’s no good way to know viral versus bacterial → default is to treat as bacterial pneumonia with antibiotics Diagnosis: Clinical features (cough, fever, sputum production, pleuritic chest pain, crackles) Guidelines recommend a chest x-ray For outpatient uncomplicated pneumonia, don’t get blood or sputum cultures For severe cases (those with risk factors for multidrug resistance, MRSA, or pseudomonas) you still want to get blood and sputum cultures Pearls: No more healthcare-associated pneumonia Emphasis on CURB-65 to assess severity of who does NOT need to be admitted Procalcitonin is NOT endorsed as a way to determine who gets antibiotics and who doesn’t Treatment: Increasing strep pneumo resistance to macrolides so no more monotherapy with macrolide (azithromycin) unless resistance is less than 20% in the area First-line in non-hospitalized adult is amoxicillin or doxycycline for 5-7 days Steroids recommended not use but may be considered in septic shock Commentary from Dr. Patel (ID specialist): Not a major change in practice other than to consider not covering atypicals in an otherwise healthy person   REFERENCES: Metlay JP, Waterer GW, Long AC, et al on behalf of the American Thoracic Society and Infectious Diseases Society of America. Diagnosis and Treatment of Adults with Community-Acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. https://www.atsjournals.org/doi/10.1164/rccm.201908-1581ST  Jain S, Self WH, Wunderink RG, et al for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015; 373:415-427. Postma DF, van Werkhoven CH, van Elden LJR, et al for the CAP-START Study Group. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med 2015; 372:1312-1323.

A cough lasting longer than 8 weeks can be a major frustration for our patients (and everyone around them). In this segment, pulmonologist and cough expert Dr. Kathryn Robinett walks Neda Frayha, MD, and Paul Simmons, MD through a real-world approach to chronic cough and drops tons of beautiful, shimmery knowledge pearls along the way. To view the references and show notes for this segment CLICK HERE   

In this Hippo Education bonus conversation, Drs. Jay-Sheree Allen and Neda Frayha sit down with noted health disparities researcher Dr. Utibe Essien, an Assistant Professor of Medicine at the University of Pittsburgh School of Medicine and Core Investigator for the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System. They explore reasons for disparities in the health care outcomes of our patients, disparities in the diversity of our medical profession, and the crucial bridge that connects these two. They close with three concrete steps we all can take to improve our clinical practice and reduce health disparities in our patient communities. CLICK HERE To view the references and join our thriving community of clinicians

Got time? A lot of our resident listeners have been asking for tips and tools for time management in the clinic. Dr. Nikki Southall joins Paul Simmons, MD, and Neda Frayha, MD for a conversation about typical time sinks, some great time management tips, and strategies for becoming more efficient at work.  Click here to view references and show notes

Race and health are inextricably linked to each other. Pediatricians Nathan Chomilo and Michael Cosimini break down the AAP Policy Statement on the health effects of racism on children. To view the references for this segment Click Here

In recent weeks, many of our medical organizations have released official statements declaring racism to be a public health crisis. In this introduction to Hippo Education’s new Race and Medicine audio series, Dr. Jay-Sheree Allen sits down with Primary Care RAP host Dr. Neda Frayha for a candid conversation exploring the definition and types of racism, the historical and present-day manifestations of racism in medicine, and potential strategies we all can incorporate into our daily practices to go beyond the hashtag and become true allies. To View the references from this segment: Click Here

Do you automatically refer to a urologist when a patient asks about a vasectomy? Have you ever considered that this procedure can actually be done in the primary care office? Our own Paul Simmons, MD discusses this with Lyrad Riley, MD in the first installment of a new series on procedural tips and tricks called: “Proceed with Confidence.”  To view the references and show notes from this segment Click Here

Drs. Brian Lin and Mike Weinstock discuss alterations to our usual practice patterns of laceration repair in the setting of the COVID pandemic, which include increasing patient throughput through faster closure techniques, reducing total points of contact with the healthcare system by using techniques to obviate the need for a return visit, and habit changes during closure to minimize exposure risk during face-to-face contact.   To view the references and show notes from this podcast Click here

How are you coping with all of the death around us these days? In this Hippo Education update, Primary Care RAP host Dr. Neda Frayha interviews Dr. BJ Miller, a hospice and palliative care specialist at the University of California, San Francisco whose TED talk on what really matters at the end of life has been viewed over 10 million times. Along with Shoshana Berger, Dr. Miller is the co-author of the book, A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death and founder of the Center for Dying and Living. In this conversation, he helps us come to terms with our own mortality and provide better support to our patients at the end of life.    To view the references and show notes from this podcast Click here

Dr. Mizuho Morrison & Dr.Jenny Beck Esmay both having had covid themselves, briefly discuss the clinical course and what presence of IgM vs. IgG signifies. They discuss what we currently know about antibody testing (national availability, reliability, sensitivity) as well as convalescent plasma transfusion (CPT) and criteria for donation vs. recipient.   To view the references and show notes from this podcast Click here

*Editor's note: As of June 4, 2020, The Lancet article by Mehra MR et al has been retracted. (https://www.thelancet.com/lancet/article/s0140673620313246) In this Hippo Education short, Dr.Salim Rezaie from REBEL EM and Lit Matters critically appraises two papers published on Friday May 22nd, 2020.  He discusses what the evidence shows for both remdesivir & hydroxychloroquine/chloroquine as effective treatment or prophylaxis for COVID-19.   To view the references and show notes from this podcast Click here

COVID-19 causes STEMI’s, arrhythmias and myocarditis?!? Emergency medicine and cardiology guru Amal Mattu, MD chats with Mizuho Morrison, DO on the cardiovascular effects of COVID-19. They discuss: the known pathophysiology of how viral infections affect the heart; Review the new consensus statement from the Society of Cardiovascular Angiography and interventions (SCAI), American College of Cardiology (ACC), and the American College of Emergency Physicians (ACEP) on how to manage STEMIs; and lastly discuss how cardiac arrest management differs in this COVID era.    To view the references and show notes from this podcast Click here

Children seem to be less affected than adults by the direct effects of COVID-19 infection, but the pandemic has brought forth other health risks to the pediatric population. Sol Behar interviews Oakland, CA based primary care pediatricians Celine Sparrow and Katie D’Harlingue about the indirect  impact of COVID-19 on children. Topics covered include home school and academic achievement, mental health issues, and nutrition/food insecurity.  To view the references and show notes from this podcast Click here

Are you an expert in continuous glucose monitors and how to use them? Great! Then you can teach us! If not, endocrinologist and friend of the podcast Dr. Beth Lamos is back to walk us through the indications for CGMs and practical ways to use them in our patients. View the show notes and references by  CLICKING HERE

In this Hippo Education update, Primary Care RAP host Dr. Neda Frayha interviews regular guest and Infectious Diseases expert Dr. Devang Patel for a discussion of where the IDSA stands on all the potential treatments for COVID-19, a review of the remdesivir paper that is all the rage lately, and a look back on whether or not their very first conversations on the novel coronavirus have stood the test of time.    To view the references and show notes from this podcast Click here

Sol Behar, MD interviews New York City pediatric emergency physician Dr. Ee Tay, highlighting the features of pediatric COVID disease, including an emerging illness that is being compared to Kawasaki Shock Syndrome called “pediatric inflammatory multisystem disease” (PIMS). To view the references and show notes from this podcast Click here

Dr. Matthieu DeClerck talks to Dr. Manie Beheshti on how the healthcare system should approach the “re-opening” of society as we plan the lifting of social restrictions. What safety implementations need to be in place in order to protect our most vulnerable patients. What changes can we anticipate in the healthcare system moving forward? To view the references and show notes from this podcast Click here  

Have you ever had a patient who is on peritoneal dialysis? What does this even mean? How does it work? Paul Simmons, MD and Neda Frayha, MD answer these questions and more in this 2 part-segment about peritoneal dialysis.  To see the show notes and references  Click Here  Subscribe today to hear Part 2 and the rest of this month's program.  

In this Hippo Education Short, psychiatrist Dr. Melissa Shepard sits down with Primary Care RAP host Dr. Neda Frayha for some real talk on the mental health challenges facing health care workers in the COVID-19 pandemic, and some concrete, tangible tools to help us get through this period. Spoiler alert: it’s more than yoga.    To view the references and show notes from this podcast Click here

Dr. Matthew DeLaney and Dr. Michael Weinstock sit down to discuss the threat of lawsuits in the midst of the COVID pandemic. The last thing anyone wants to think about is the risk of a lawsuit. Unfortunately, despite the extra challenges posed by our current pandemic, the threat of medicolegal consequences remains. In this segment, we evaluate the unique medicolegal risks that can occur during disaster situations and look at potential sources of medicolegal protection. To view the references and show notes from this podcast Click Here

Drs. Mike Weinstock and Josh Russell, from Urgent Care RAP, just published a landmark COVID study: CXRs obtained from confirmed and symptomatic COVID-19 patients presenting to the UC were normal in 58.3% of cases, and normal or only mildly abnormal in 89% of patients. Matthew DeLaney, MD joins in on the conversation in this important podcast. To view the references and show notes from this podcast Click here

Highlights IVF: Keep patients dry but not too dry; check the IVC; Scott prefers LR Furosemide: Only if iatrogenically fluid-overloaded Vasopressor: Norepinephrine sooner rather than later in a hypotensive COVID patient Corticosteroids: Scott's team is doing Dexamethasone 10mg qdaily to any admitted patient with respiratory failure; Methylprednisolone 60mg q6hr for those with rising inflammatory markers (CRP, D-dimer); Methylprednisolone 125mg q6hr if critically ill Anticoagulation: Scott's team is giving prophylactic enoxaparin to all hospitalized patients; if D-dimer is rising, full treatment dose of enoxaparin To view the references and show notes from this podcast Click Here 

Hospitals are calling clinicians in to help with COVID inpatient care. Part 3 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines. Highlights Initial COVID ventilator settings: Volume AC mode, Tidal volume of 8 mL/kg of ideal body weight, Respiratory rate of 16 to 18 breaths per minute, FiO2 of 100%, and PEEP of 8 cmH2O Ventilator alarming? Think “DOPE” (displaced tube, obstruction, pneumothorax, equipment failure) To view the references and show notes from this podcast Click Here

Hospitals are calling clinicians in to help with COVID inpatient care. Part 2 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines. Highlights Preoxygenate using CPAP with a viral filter Induce and paralyze while the patient is sitting up Avoid post-intubation auscultation and confirm with ETCO2 Avoid using the BVM until after the patient is intubated To view the references and show notes from this podcast Click Here

Hospitals are calling clinicians in to help with COVID inpatient care. Part 1 of 4 in this critical care crash course with Dr. Scott Weingart and Dr. Mizuho Morrison on the latest "What if I get called in?" podcast. Just-in-time critical care pearls and pitfalls from the frontlines. Highlights COVID “happy hypoxemics” may require intubation if they have:  Any increased work of breathing (tachypnea is common but they should be a “happy tachypneic”) Altered mental status Rising CO2 on serial VBGs Oxygen saturation consistently below 80-85% To view the references and show notes from this podcast Click Here  

Patients with COVID-19 present in a variety of ways and clinicians need to have a low index of suspicion for diagnosis. Management involves emergency referrals for patients with low oxygen saturation. Every patient should be treated as if they could have COVID-19. Mike Weinstock, MD, and Matthieu DeClerck, MD are joined by Frank Illuzzi, MD in this very important segment.  To view the references and show notes from this podcast Click Here

Covid-19 is a rapidly spreading pandemic that has already had worldwide ramifications. As Emergency Rooms and Hospitals quickly get overwhelmed by ill patients, the Urgent Care and Primary Care setting play critical roles in appropriately triaging patients that can go home vs those that need to be transferred to the Emergency Department for further evaluation and treatment. The ability to act as levies to the large number of patients during this pandemic will help preserve the ED and Hospital “resources” for those critically ill patients that need it most.  In order to help UC and PC providers make these decisions the College of Urgent Care Medicine (CUCM) and the American College of Emergency Physicians (ACEP) have published a set of criteria that break suspected Covid-19 patients into 2 categories. Category 1, who can go home; and Category 2, who should be transferred to the ED. To view the references and show notes from this podcast Click Here

There are so many active threads, subthreads, and sub-sub-threads of conversation in the medical community surrounding the COVID-19 pandemic. In this Hippo Education Short, Tom Robertson, MD and Steve Biederman, MD of Primary Care RAP’s Paper Chase take 4 hot topics in COVID-19 and examine the literature behind them. They look into the epidemiology of the outbreak in the U.S. and lessons learned, the sensitivity and specificity of SARS-CoV-2 testing, the rates of co-infection with other respiratory viruses, and convalescent plasma as a potential therapy. To view the references and show notes from this podcast Click Here

Mizuho Morrison, DO sits down with emergency medicine pharmacist/toxicologist Bryan Hayes, PharmD to answer some pertinent questions and myth-bust clarifications about pharmaceutical options in COIVD-19 treatment. To view the references and show notes from this podcast Click Here

Sometimes it can seem like every other child we see has a food allergy. How prevalent are food allergies in the general population, and how can we best diagnose and manage them? To shed light on these questions, as well as recent guideline changes in the allergy community and novel therapies on the horizon, PC RAP welcomes back Torie Grant, MD MHS a Med/Peds allergist and immunologist at Johns Hopkins. She sits down with Neda Frayha, MD to share the full scoop on food allergies. To hear Part Two of this conversation and to view the show notes as well as detailed references click here

Sol Behar, MD interviews Children’s Hospital of Philadelphia NICU doc Joanna Parga-Belinkie, MD to discuss Covid-19 and some of the peripartum issues that come up during the novel coronavirus pandemic for both pregnant moms and their newborns. For the show notes and additional references please click here

Has your clinical practice shifted to telemedicine yet? In the era of COVID-19, clinicians everywhere are being thrown into telemedicine, often without any experience or background knowledge. To help us all get up to speed with this patient care technology, Hippo Education’s Dr. Neda Frayha sits down with Dr. Edward Kaftarian, the Vice Chair of Mental Health at the American Telemedicine Association and CEO of Orbit Health Telepsychiatry. Together they explore the benefits and potential pitfalls of telemedicine, the equipment required, billing and coding considerations, appropriate etiquette, and much more. For more information and to view all the detailed notes and get all the references for this segment please click here

We know that there's a constant flood of information. So, we produced this podcast mini-series to help rapidly onboard healthcare professionals who don’t see COVID-19 patients regularly. We’re going to keep this simple and short, something you can listen to on your drive into work. We'll point out key clinical pearls and pitfalls that we've learned on the frontlines to help keep you and your patients safe. You can do this. Featuring Aaron Bright, MD and Salim Rezaie, MD

Most healthcare professionals know what personal protective equipment (PPE) is, but the reality is that many of us don’t use this everyday and are wondering if we’re doing it correctly. Let’s highlight where people make mistakes and expose themselves to risk. Featuring Aaron Bright, MD and Salim Rezaie, MD

For healthcare professionals who may get called in to help with COVID-19 patients, you will most likely be asked to help triage and manage ambulatory suspected COVID-19 patients. Here’s what you need to know. Featuring Aaron Bright, MD and Salim Rezaie, MD

Most healthcare professionals are familiar with oxygen supplementation and nebulizers, maybe even CPAP/BiPAP. Most of us should have some Basic Life Support (BLS) training to use a bag-valve-mask (BVM) in case of emergency. But there are some of this changes with COVID-19. Featuring Aaron Bright, MD and Salim Rezaie, MD 

For healthcare professionals who do not often receive immediate laboratory results and diagnostic imaging reports, we’ll highlight unique diagnostic patterns and pitfalls with COVID-19 patients. Featuring Aaron Bright, MD and Salim Rezaie, MD

As healthcare professionals, we all recognize the increased risks we face as we care for our patients during the COVID-19 pandemic, but we must also care for ourselves, especially when we come home to our families. It’s normal to be concerned and one of the first things we can do is to start having conversations and plan ahead. Featuring Aaron Bright, MD and Salim Rezaie, MD

Our panel of podcast hosts from a variety of practice settings discuss the logistical and psychological impact of the COVID-19 pandemic on healthcare workers and discuss strategies to mitigate the stress associated with the pandemic.  Featuring:  Solomon Behar, MD, Neda Frayha, MD, Mike Weinstock, MD, and Matthieu DeClerck, MD  For References: Click Here  

In this Hippo Education Short, Infectious Diseases specialist Dr. Devang Patel and our own Dr. Neda Frayha discuss the latest, clinician-focused updates on the COVID-19 coronavirus outbreak.  Subscribe to Primary Care:RAP today to support this show and the important work being done to provide you with the most up-to-date medical knowledge from the world experts in the field.  http://www.hippoed.com References Available at  https://www.hippoed.com/pc/rap/episode/bonusshortcovid/covid19update

When we treat patients, whether in the hospital or outpatient setting, involving their family members can lead to improved outcomes. Tom Robertson, MD, and Mizuho Morrison, DO discuss the engagement of family members with Giora Netzer, MD, MSCE who literally wrote the book on family centered care.    For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year. 

We have been waiting and waiting and waiting for the new community acquired guidelines. And here they are! Infectious Diseases expert Dr. Devang Patel, MD joins Matt DeLaney, MD, FACEP, FAAEM and Neda Frayha, MD for a conversation on CAP in general and the new guidelines in specific. For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.  Pearls: The latest guidelines for community acquired pneumonia now includes amoxicillin or doxycycline for 5-7 days as first-line treatment given the rising rates of macrolide resistance and less emphasis on coverage of atypical pneumonia pathogens. Review of pathophysiology: Lower respiratory tract often preceded by an upper respiratory tract infection, that inhibits ability to clear mucus and pathogens invade the lungs Other risk factors: Smoking Elderly Immune compromise (ie: infection, steroids, cancer) Pathogens: Typical - strep pneumo, haemophilus, staph aureus Atypical (more common) - influenza, parainfluenza, mycoplasma, chlamydia pneumoniae, legionella, coccidioidomycosis (in the southwest) EPIC Study (2015) - study to determine pneumonia pathogens using all the tools we have available (culture, PCR) 62% no pathogen detected 22% viral - most were rhinovirus which does not cause lower respiratory tract infections but predisposes to pneumonia Strep pneumonia was the number one bacterial pathogen Bottomline: we still don’t know what causes most pneumonias but just that our patients get better with antibiotics Differentiating between typical v. atypical pneumonias - there’s no good way to know viral versus bacterial → default is to treat as bacterial pneumonia with antibiotics Diagnosis: Clinical features (cough, fever, sputum production, pleuritic chest pain, crackles) Guidelines recommend a chest x-ray For outpatient uncomplicated pneumonia, don’t get blood or sputum cultures For severe cases (those with risk factors for multidrug resistance, MRSA, or pseudomonas) you still want to get blood and sputum cultures Pearls: No more healthcare-associated pneumonia Emphasis on CURB-65 to assess severity of who does NOT need to be admitted Procalcitonin is NOT endorsed as a way to determine who gets antibiotics and who doesn’t Treatment: Increasing strep pneumo resistance to macrolides so no more monotherapy with macrolide (azithromycin) unless resistance is less than 20% in the area First-line in non-hospitalized adult is amoxicillin or doxycycline for 5-7 days Steroids recommended not use but may be considered in septic shock Commentary from Dr. Patel (ID specialist): Not a major change in practice other than to consider not covering atypicals in an otherwise healthy person   REFERENCES: Metlay JP, Waterer GW, Long AC, et al on behalf of the American Thoracic Society and Infectious Diseases Society of America. Diagnosis and Treatment of Adults with Community-Acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST. https://www.atsjournals.org/doi/10.1164/rccm.201908-1581ST  Jain S, Self WH, Wunderink RG, et al for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015; 373:415-427. Postma DF, van Werkhoven CH, van Elden LJR, et al for the CAP-START Study Group. Antibiotic treatment strategies for community-acquired pneumonia in adults. N Engl J Med 2015; 372:1312-1323.

In this Hippo Education Short, Infectious Diseases specialist Dr. Devang Patel sits down with our own Dr. Neda Frayha to discuss what we know so far about the new 2019-n-CoV coronavirus outbreak and what front-line clinicians can do if we suspect a patient of ours might have this viral illness.  References: Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med, 24 Jan 2020. DOI: 10.1056/NEJMoa2001017.  Munster VJ, Koopmans M, van Doremalen M, et al. A novel coronavirus emerging in China - key questions for impact assessment. N Engl J Med, 24 Jan 2020. DOI: 10.1056/NEJMp2000929 Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet, 24 Jan 2020. https://doi.org/10.1016/ S0140-6736(20)30183-5    Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet, 24 Jan 2020. https://doi.org/10.1016/S0140-6736(20)30154-9 Phan LT, Nguyen TV, Luong QC, et al. Importation and human-to-human transmission of a novel coronavirus in Vietnam. N Engl J Med, 28 Jan 2020. DOI: 10.1056/NEJMc2001272 Wuhan Coronavirus - 2019-n-CoV. Infectious Diseases Society of America. https://www.idsociety.org/public-health/wuhan-coronavirus/. Accessed 29 Jan 2020 2019 Novel Coronavirus (2019-n-CoV), Wuhan, China. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/summary.html. Accessed 29 Jan 2020. Update and Interim Guidance on Outbreak of 2019 Novel Coronavirus (2019-n-CoV) in Wuhan, China. Centers for Disease Control and Prevention. https://emergency.cdc.gov/han/han00426.asp. Accessed 29 Jan 2020.   Resource: Centers for Disease Control and Prevention 2019-n-CoV PUI Case Investigation Form: https://www.cdc.gov/coronavirus/2019-ncov/downloads/pui-form.pdfpdf icon

Primary Care RAP has covered the start-screening-mammos-at-age-50 perspective in the past. Today, we’ll explore the other side of the coin: why women’s health focused organizations recommend beginning annual screening mammography at age 40. Neda Frayha, MD sat down with Dr. Alison Chetlen, DO a breast imaging expert and Associate Professor and Vice Chair of Education in the Department of Radiology at Penn State Health and Hershey Medical Center, for a deeper dive into the evidence we don’t always hear about in primary care. 

Hoarseness is a common complaint in the primary care setting. Our ENT colleague, Dr. Elizabeth Guardiani, sits down with Drs. Matt DeLaney and Neda Frayha to discuss how we can approach this in primary care as well as when to refer to a specialist.  For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and you'll stay up-to-date on all the latest with your favorite Primary Care RAP hosts and contributors.

We all know what to do in pre-op visits for non-cardiac surgery. But guidelines on the pre-op management of cardiac surgery patients are hard to find. Neda Frayha, MD sat down with Dr. Michael Grant, a cardiac anesthesiologist at the Johns Hopkins University School of Medicine, to learn what we need to worry about (and what our pre-op evaluations should include) when our patients go off to cardiac surgery. For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year. 

 It all started when Paul and Neda researched porphyria to answer a mailbag question. Paul couldn’t get the song ‘Ophelia’ by the Lumineers out of his head. So he did what any self-respecting lyrical genius would do and wrote a different version of the song. Hippo Education’s own Melinda Hershey brought her vocal talent to the collaboration, and voila - ‘Oh, Porphyria!’ was born.   For more incredible education like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.   

Post-contrast AKI (or contrast induced nephropathy as it used to be called) is one of those hot-button issues in modern medicine. Is it really a thing? Was it ever, really? Neda Frayha, MD sits down with Dr. Salim Rezaie of Rebel EM for an invigorating conversation about this controversial topic and what the literature actually tells us about it.    For more incredible segments like this, subscribe to PC:RAP today. You'll never miss a moment of the program and earn 42 hours of CME per year.